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I
FINAL DRAFT
Islamic Republic of Afghanistan
Ministry of Public Health
COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN (HCWMP)
FOR THE SYSTEM ENHANCEMENT FOR HEALTH ACTION IN TRANSITION (SEHAT)
PROJECT
October, 2014
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Table of Contents
ABBREVIATIONS AND ACRONYMS V
EXECUTIVE SUMMARY 1
I. INTRODUCTION 21
BACKGROUND OF HCWM IN AFGHANISTAN: 21
II. POLICIES, LEGISLATION AND REGULATION 23
ENVIRONMENTAL PROTECTION ACT, 2007 23
MOPH STRATEGIC PLAN 23
INFECTION PREVENTION AND CONTROL POLICY, 2005. 24
WORLD BANK SAFEGUARD POLICIES 24
IAEA SAFETY STANDARDS SERIES OCCUPATIONAL RADIATION PROTECTION 25
HEALTH CARE WASTE 26
III. SITUATION ANALYSIS OF HCWM IN AFGHANISTAN 27
STRUCTURE OF THE HEALTH CARE SERVICES DELIVERY SYSTEM: 28
PRIORITY POLICIES: 28
DEVELOPMENT OF COMPREHENSIVE HCWM PLAN 29
CURRENT HEALTH CARE WASTE MANAGEMENT PRACTICES IN THE AFGHANISTAN HEALTH CARE CENTERS: 31
WASTE ESTIMATE 34
DISPOSAL SITE ANALYSIS 37
SCAVENGING & RECYCLING 37
TRAINING NEEDS ASSESSMENT 38
IV. HEALTH CARE WASTE MANAGEMENT PLAN 38
V. ORGANIZATIONAL ARRANGEMENTS FOR IMPLEMENTATION 55
A. NATIONAL LEVEL 55
B. PROVINCIAL LEVEL: 56
III
VI. OPERATIONAL FRAMEWORK 64
AWARENESS AND TRAINING 72
VII. MONITORING 75
VIII. BUDGET 78
DISCLOSURE 0
LIST OF REFERENCES 0
IV
List of Tables & Figures
Table 1: Current status of health care waste management practices. ......................................................... 5
Table 2: Gaps and Objectives for HCWM ...................................................................................................... 8
Table 3: Health Care Waste Categories and Descriptions .......................................................................... 26
Table 4: Health Effects and Potential Hazards from Clinical Wastes .......................................................... 27
Table 5: Existing Waste Management Practices in Afghanistan ................................................................. 32
Table 6: Illustration of Estimate of Healthcare Waste Generation in Afghanistan ................................... 35
Table 7: Quantity of HCW in Afghanistan .................................................................................................. 36
Table 8: Training Needs Assessment ...................................................................................................... 38
Table 9: HCWM Plan Activities of Major Components ............................................................................... 40
Table 10: Recommended Color Codes ........................................................................................................ 46
Table 11: Health Care Waste Management guidelines (HCWMP) Matrix for SEHAT ................................. 50
Table 12: Categories of health-care waste and their final disposal decision matrix .................................. 53
Table 13: Role of different stakeholders in health care waste management............................................. 59
Table 14: Additional regulatory guidelines ................................................................................................. 59
Table 15: Proposed implementation schedule for HCWM Plan ................................................................ 63
Table 16: General Waste Management Rules ............................................................................................ 68
Table 17: SHC, BHCs, and CHCs’ Wastes ..................................................................................................... 69
Table 18: Instruction for use of AD syringes ............................................................................................... 70
Table 19: Training of the Trainers (TOT) Program ...................................................................................... 73
Table 20: List of Indicator for monitoring of HCWM .................................................................................. 76
Table 21: Phase Manufacturing Program for the major Equipment & consumables ................................. 78
Table 22: Estimate of Financial Requirement for Training, Capacity Building and IEC (US Dollar) ............ 81
Table 23: Estimate of Financial Requirement for Technology Up-gradation and new Procurement (US
Dollar) .......................................................................................................................................................... 81
Figure 1: Sample Wheeled Vehicles (Source: WHO) ................................................................................... 49
Figure 2: International Infection Substance Symbol ................................................................................... 49
Figure 3 : Schematic Representation of Institutional Capacity building of various stakeholder for proper
implementation of HCWM plan .................................................................................................................. 58
Figure 4: Existing HCWM- M&E Framework .............................................................................................. 75
Figure 5: Year wise Investment Required ................................................................................................... 79
V
List of Annexure
ANNEXURE II: MAJOR SCOPE OF WORK ....................................................................................................... 1
ANNEXURE III: COPY OF THE QUESTIONNAIRES USED................................................................................. 5
ANNEXURE IV: LIST OF CONTACTS ............................................................................................................ 115
ANNEXURE V: GUIDELINES FOR SETTING UP WASTE MANAGEMENT COMMITTEE................................ 120
ANNEXURE VI: GUIDELINES FOR CONSTRUCTION SHARP AND BURIAL PITS ............................................... 0
ANNEXURE VII: COMPARATIVE EVALUATION OF DIFFERENT TECHNOLOGY ................................................ 0
ANNEXURE VIII : GUIDELINES FOR SETTING UP OF CWTFs ........................................................................... 0
VI
ABBREVIATIONS AND ACRONYMS
AD : Auto Disabled
AHNSS : Afghanistan Health and Nutrition Sector Strategy
ARTF : Afghanistan Reconstruction Trust Fund
BHC : Basic Health Centre
BPHS : Basic Package of Health Services
CBHC : Community Based Health Center
CBR : Capacity for Result
CDC : Center for Disease Control and Prevention
CHC : Comprehensive Health Centre
CWTF : Common Waste Treatment Facility
EC : Environmental Clearance
EMP : Environment Monitoring Plan
EMS : Environmental Management System
EPHS : Essential Package of Health Services
ESMF : Environmental & Social Management Framework
GDo PM : General Directorate of Preventive Medicine
GIZ : Deutsche GesellschaftfürInternationaleZusammenarbeit (GIZ)
GoA : Government of Afghanistan
HCS : Health Care Services
HCU : Health Care Unit
HCW : Health Care Waste
HCWM : Health Care Waste Management
HCWMP : Health Care Waste Management Plan
HFs : Healthcare Facilities
HMIS : Health Management Information System
HNS : Health and Nutrition Sector
HW : Health Worker
IMEP : Infection Management and Environment Management Plan
IP : Infection Prevention
M&E : Monitoring and Evaluation
MDGs : Millennium Development Goals
MOPH : Ministry of Public Health
MSW : Municipal Solid Waste
NEPA : National Environmental Protection Agency
NGO : Non-Governmental Organization
PPA : Performance-based Partnership Agreement
PPE : Personal Protective Equipment
PPD : Provincial Project Directorate
PPP : Public Private Partnership
RBP : Results Based Planning
SC : Sub-Centre
VII
SEHAT : System Enhancement for Health action in Transition
SHARP : Strengthening of Health Activities for the Rural Poor
SHC : Sub health Center
SLF : Sanitary Landfilling
TPD : Tones per day
UNEP : United Nation Environment Program
USAID : United State Agency for International Development
WB : World Bank
WHO : World Health Organization
1
EXECUTIVE SUMMARY
1. MAIN OBJECTIVE
The main objective of this document is to provide an environmentally sound, technically feasible,
economically viable and socially acceptable healthcare waste management Plan for Afghanistan with
cost implication and timeframe for implementation of the same.
2. DEFINITION OF HCWM: Health care waste management (HCWM) is a process to help ensure
proper hospital hygiene and safety of health care workers and communities. It includes planning and
procurement, construction, staff training and behavior, proper use of tools, machines and
pharmaceuticals, proper disposal methods inside and outside the hospital, and evaluation. Its many
dimensions require a broader focus than the traditional health specialist or engineering point of view.
3. ADVANTAGES OF GOOD HCWM
The need for proper HCWM has been gaining recognition slowly. It can help control nosocomial
diseases (hospital acquired infections), complementing the protective effect of proper hand washing;
reduce community exposure to multi-drug resistant bacteria; dramatically reduce HIV/AIDS, sepsis,
and Hepatitis transmission from dirty needles and other improperly cleaned/disposed medical items;
control zoonosis (diseases passed to humans through insects, birds, rats and other animals); cut
cycles of infection; easily and cost-effectively address health care worker safety issues, including
reducing risk of needle sticks; prevent illegal repackaging and resale of contaminated needles; avoid
negative long-term health effects; e.g., cancer, from the environmental release of toxic substances
such as dioxin, mercury and others.
HCW can be subdivided into various categories. Segregation of different waste categories is
critically important to enable proper disposal. Approximately 80% of all HCW can be disposed of
through regular municipal waste methods. The other 20% can create serious health threats to health
workers and communities if not disposed of properly. Disposal methods vary according to type of
waste, local environment, available technology, costs and financing, and social acceptance. Lance
Healthcare Waste (HCW): All waste produced in a health-care unit is defined as Health-Care
Waste but practically 75-90% of HCW is general waste which is non-infectious and similar in nature
to Municipal Solid Waste (MSW).
The remaining 10-25%of the HCW comprising of Infectious Waste (Sharp Waste, Contaminated
dressings, anatomical and body parts), Chemical or Pharmaceutical Waste and small amounts of
radioactive, cytotoxic or Mercury-based waste, represents an elevated risk as a source of potential
infection, injury or other health impact. A miniscule fraction (generally less than1%) may pose a
serious chemical, radiological or physical hazard.
Infectious waste, if not managed properly, can endanger the health of patients, health-care workers,
waste-pickers and the people at large and can lead to people dying or getting injured or sick. Sharps
Waste poses the highest risk among the entire range of Infectious HCW. The WHO estimates that the
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unsafe injection practices may cause 1.3 million people1 premature death a year. Improper
occupational practices and waste handling of infectious waste poses a high risk to health care
workers, environment-service staff, waste handlers and the general public.
Waste generated from specific programs/projects is also classified as a HCW. The improper usage of
insecticides, pesticides etc. such as rodenticides for control of rats and mice, antimicrobial pesticides,
bleach etc. can result in increased contamination of soil and water if precautionary measures are not
taken. The final step in rendering the HCW non-infectious is its treatment and disposal. Various
technologies are available as alternatives for treating different types of HCW including Chemical
Infection, Incineration, Autoclaving, Hydroclaving, Microwaving and the Deep Burial.
There is need to build up the local skills and the expertise for operating the various types of HCWM
equipment including the incinerators, autoclaves, microwaves, chemical disinfection, sharps
management, as well as the operation of the sanitary land filling facilities. The operational skills as
well as the construction technology for the Deep Burial Pits also need to be developed.
4. HEALTHCARE SERVICES DELIVERY SYSTEM IN THE COUNTRY
Healthcare Services is provided in the country through BPHS and EPHS packages.
a. Basic Package of Health Services (BPHS)
The purpose of developing the BPHS was to provide a standardized package of basic services
that would form the core service delivery package in all primary health care facilities. The
BPHS represented a roadmap that provided policymakers with a clear sense of direction and
emphasized essential primary health care as the basis of the health system. As a result, the
BPHS has been the catalyst behind the establishment of strong understandings between the
MoPH and its major partners; namely the BPHS implementing NGOs and the donors.
The standardized classifications of health facilities that provide the basic services now include
the following:
o Health Posts (HPs)
o Health Sub-centers (HSCs)
o Basic Health Centers (BHCs)
o Mobile Health Teams (MHTs)
o Comprehensive Health Centers (CHCs)
o District Hospitals (DHs)
The major healthcare services provided under the BPHS include Maternal and New born care,
Child Health and Immunization, Public Nutrition, Communicable Disease and Treatment and
Control, Mental Health and Disability and Physical Rehabilitation services and regular supply
of essential drugs.
1 Bulletin of the WHO,1999,77(10)
3
Thus type of HCW which could be generated through the BPHS package would include
Anatomical Waste, Sharps, Infectious Waste including dressing etc. b. ESSENTIAL PACKAGE OF HOSPITAL SERVICES (EPHS)
The Essential Package of Hospital Services (EPHS) has three purposes: (1) to identify a
standardized package of hospital services at each level of hospital, (2) to provide a guide for the
MOPH, private sector, nongovernmental organizations (NGOs), and donors on how the hospital
sector should be staffed, equipped, and provided materials and drugs, and (3) to promote a
health referral system that integrates the BPHS with hospitals. The EPHS defines, for the first
time, all the necessary elements of services, staff, facilities, equipment, and drugs for each type
of hospital in Afghanistan.
These packages have direct relation with the healthcare waste generation, handling and management
of the same in the country. The improvement of healthcare services delivery system means increment
in number of people who would get more accessibility of healthcare services and treatments. This
would require consideration while formulating the healthcare waste management plan in the country.
5. DEVELOPMENT OF COMPREHENSIVE HEALTHCARE WASTE
MANAGEMENT PLAN
The MoPH developed a Preliminary HCWM Plan for the first 6 months of the SEHAT project in
2012. The major interventions that were recognized included development and adoption of
guidelines for effective healthcare waste management, creating awareness and training to the end
user/the waste producer/waste handler.
The preliminary HCWM plan was not purported to cover many issues in detail.
The MoPH recruited and international consultant to work on development of a comprehensive
healthcare waste management plan. The consultant along with the officials from the Environmental
Health Directorate, MoPH undertook field visits in Kabul, Ghazak, Parwan, Panjashir, and Balkh
Provinces having detailed interactions with various stakeholders such as the HCFs( National
Hospitals, Regional Hospitals, Provincial Hospitals, District Hospitals, CHCs, BHCs), International
Funding Agencies, Department of MoPH, NGOs, Landfill Sites, Municipalities, Regulatory bodies,
other relevant agencies etc. Structured Questionnaires were used for eliciting responses from the
HCFs in addition to interaction with the Staff there. For other respondents, unstructured and Semi-
structured Questionnaires were used to get their inputs, in conformity with the objectives of the
HCWMP.
The inputs from the desk research, and interaction with the stakeholders were useful in assessing the
regulatory framework and its compliance in practice, present status of HCWM at different types of
HCFs, quantities of HCW generated, current technology in use for treatment of HCW and its
disposal, Monitoring & Evaluating mechanism, Training Needs Assessment etc. The specific issues
such as segregation of HCW and color coding practices, type of equipment in use for collection &
transportation, use and disposal of Sharps, development of Landfill facilities for HCW disposal,
status of Infection Control etc. were addressed. The plans for management of HCW from rural areas
have been worked out separately based on the interaction with the various stakeholders
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These inputs were useful in developing recommendations for the HCWM Plan. A gap analysis was
also undertaken to compare the present status and the recommendations made. The Comprehensive
HCWMP duly incorporates the gap analysis as well as the capacity of the various stakeholders to
adopt and implement the proposed plan.
The plan contains major guidelines to be followed during the implementation stage , provision of
pilot projects for CWTFs, alternate technologies for the remote and rural areas, 3rd party monitoring
and evaluation framework, format & contents of training programs, procurement policy for major
treatment technologies and safety equipment, construction guidelines for sharp and burial pits etc.
apart from other aspects such as Segregation, Color Coding, Infection Management , Transportation,
Disposal, Sharps Waste Management etc.
6. REVIEW OF EXISTING POLICY FRAMEWORK
Existing Policy Framework which are relevant for Healthcare Waste Management include:
i) Constitution of the Islamic Republic of Afghanistan
ii) Environmental Law of the Islamic Republic of Afghanistan , 2007
iii) Environmental Impact Assessment Regulations, 2007 & 2008
iv) MoPH Strategic Plan, 2011
v) Infection Prevention Control Policy, 2005
vi) World Bank Safeguard Policies
vii) IAEA Safety Standards Series Occupational Radiation Protection
On assessment of existing policies, the finding is that there is a enough provisions to deal with the
healthcare wastes but the role and responsibility are not clear. It creates ambiguity about the
accountability at each level from regulatory authority to healthcare service facilitators. This makes it
imperative that the country should have a clear cut rules and regulation, guidelines and standards to
be maintained, establishment of linkages between different applicable acts and policies, designation
of body, a waste management committee, functions, clear guidelines on ‘reporting system and
provision of 3rd
Party Monitoring and Evaluation. Like other country, this rule can be christened as
‘Healthcare Waste Management & Handling Rule’.
7. ESTIMATE OF HEALTHCARE WASTE GENERATION IN AFGHANISTAN
The estimate of Healthcare Waste (HCW) and the Biomedical Waste in Afghanistan has been
worked out on the basis of prevailing norms of generation of Anatomical Waste, Sharps Waste and
other Infectious wastes as well as the general waste (please see Table 4. The total HCW generated in
Afghanistan is approx.150 tons per day of which about 27 tons per day is the Bio Medical waste and
the rest is the General Waste.
5
There are around 1989 Health Care Unit situated in Afghanistan and gross total waste generated is
27.0 tones out of which 6.6tonnes are anatomical wastes, 14.8 are sharp wastes and 5.6tonnes are
other infectious wastes2.
The HCW generation in Afghanistan has been worked out on the basis of the number of different
types of HCUs and the HCW generated at each of these units from the OPD facilities as well as In
house Patients (see Table 4 & 5,
8. EXISTING WASTE MANAGEMENT PRACTICES IN AFGHANISTAN
The prevailing Healthcare Waste Management Practices in Afghanistan has been given below in
tabular form. It has been prepared based on discussions with various stakeholders
Table 1: Current status of health care waste management practices.
Operation Existing Practices/Status
Waste Generation i) Waste Generation not monitored primarily because of lack of
proper collection and segregation
Waste Collection i) Waste Collected from the OT, General Wards, OPD Lab etc, gets
mixed generally.
ii) Apart from the sharps & Placentas, most of the other waste is
collected
iii) Needle-cutters/Hub –Cutters not used generally
Waste Segregation i) General Waste, anatomical waste, & other Infectious wastes are
normally collected separately at the point of generation
ii) Sharps (used AD syringes) collected separately in yellow Boxes,
but end up getting mixed during transportation.
iii) Patients/Visitors in the wards sometimes dump the general waste in
the bins near the Nursing Stations
Color Coding i) Color-coding exists only as far as usage of yellow Boxes for used
AD syringes and Black bins for other wastes
ii) No Color-Coding for Bags & the trolleys in which wastes are
transported
iii) The color-coding for different types of HCW is not consistent
and used more as an exception than as a rule lack of Consistency
in color-coding often results in different types of HCW getting mixed
Waste Transportation i) Primary Waste Transportation3 in Bags Carried manually by
trolleys by the Hospital Sanitation Workers
ii) Secondary Transportation is non-existent as the disposal takes place
inside the HCU primarily.
Training i) Most of the Doctors, Nurses & Para-medical staff have been trained
in Infection Prevention as per the Country’s IP Policy
ii) The training schedule & re-training as per the IP Policy is not
followed.
2 Health Care Waste assessment report, produced by Pradeep Dadlani.
3 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area
within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage
areas to the Treatment/Disposal Site.
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iii) Virtually no training is being done on HCWM
Waste Management
Committee
i) No Provision for a waste Management Committee at HCU level
ii) Focal Person for HCWM not appointed in most of the HCUs
Secondary Storage4
i) No proper provision for Secondary Storage of HCW.
ii) No timeframe earmarked for Secondary storage of HCW before its
disposal.
Treatment & Waste
Disposal
i) No clear cut policy on HCW treatment and disposal
ii) After basic segregation, all hazardous waste either burnt in
ovens/single chamber Incinerators or is buried inside the compound
iii) No disinfection equipment such as
Microwave/Autoclaves/Shredders installed except a few hospitals
Technology i) No Comparative evaluation of various technologies for HCW
treatment has been or is being done.
ii) A low level of technology is in use for HCWM e.g. Single
Chamber Incinerators ovens, Drums, Cemented Kilns etc.
Equipment i) The equipment for HCW waste collection, transportation,
treatment & disposal is of poor quality with no clear set of
guidelines
ii) Non-standardized equipment is being used mostly.
Personal Protective
Equipment PPE
i) The PPE such as gloves, goggles, mask boots etc. is used partially
in some of the hospitals.
ii) The guidelines provided in the IP Policy are also not followed in
general
iii) No mechanism to monitor the extend of usage of PPE
Monitoring & Evaluation i) No M&E mechanism for HCWM is in place at HCU level
ii) M&E for HCWM recently included the work Profile for the NGOs
under the SEHAT project in the fresh bidding process undertaken in
2013
Action Plan i) No road map for implementing HCWM Plan in Place at the Central,
Provincial or the HCU level
Finance i) No separate budget for financing mechanism for HCWM provided
ii) At the HCW level there is also no budget for HCWM provided, not
even for operational costs such as Fuel for the installed incinerator
Public Private Partnership
(PPP
i) PPP in the Health Sector of providing BPHS & EPHS through
NGOs has been a success story by & large
ii) However the same is not replicated in the HCWM Sector
Personal Hygiene &
Sanitation & Pollution
Abatement
i) No major focus on Personal Hygiene such as washing of hands PPE
etc.
ii) Water Quality at HCU level & Ambient Air Quality ( where
Incinerators used) is not monitored
Construction i) Construction Guidelines for Hospital buildings exist at MoPH, but
are outdated and not followed in practice
Integrated Holistic
Approach
i) Piecemeal approach to HCWM observed at the HCU level as well
as at the Provincial, Regional & National Levels
Capacity Building of
Env. Health Department,
MoPH& other
i) No Capacity Building exercise undertaken
4 ( Storage area earmarked within the premises of the healthcare facilities for storage of wastes from different
sources)
7
stakeholders
9. DISPOSAL SITE ANALYSIS
Although Bio-Medical Waste accounts for a small fraction of HCW, if it gets mixed with large
volumes of non-infectious waste and MSW, the problem gets compounded in terms of the potential
adverse effects.
The ash from the incinerators must be disposed of in a Sanitary Landfill site. Discussions with the
Sanitation Department of Kabul Municipality revealed that a sanitary landfill (SLF) site is under
development for the MSW generated in the city. Similar SLF sites could be planned in the other
major regional centers such as Jalalabad, Herat, Ghazni, Mazar-I-Sharif cities.
The availability of the soil cover required for covering the landfilled waste on a daily basis is an
important factor in planning and designing of a SLF site. The other important criteria which need to
be considered for the Disposal/SLF Site include the soil characteristics at the site, ground and surface
water analysis, quantum of waste to be landfilled, provision for a recycling/processing facility,
availability of land, terrain and other local factors etc. All these factors need to be taken into account
while planning a Disposal/SLF.
A visit to the Gazak Landfill site revealed that presently the HCW mixed with the MSW is being
disposed of at the site. Aerobic composting of the organic fraction of the MSW is taking place. An
area of 4000 m2 has been earmarked at the Ghazak- II landfill site for disposal of HCW generated in
Kabul.
10. ASSOCIATED UTILITY SERVICES
The basic utility services such as Sanitation, Water Supply and Solid Waste Management are an
important factor in protecting patients and staff from potential risks. Inadequate and poor
management of these services could have adverse impacts, such as outbreaks of water-borne diseases
including Viral Hepatitis, Typhoid, Cholera, Diarrhea etc. Moreover, poor management of the non-
infectious general waste such as inadequate storage, poor collection and disposal could attract stray
animals waste-pickers thereby becoming grounds for vector-borne, water-based and fecal-oral
infections. The dumping of solid wastes around the HCU could cause blockage of access roads,
water and sewage drains, resulting in an unhygienic environment for protection of health services.
During the field study it has been found that hospitals located in urban areas are well connected with
Municipal Solid Waste System and collection and transportation of general wastes are being done on
an regular basis but incidence of mixing up of general wastes with healthcare wastes often takes
place. This often takes place because of a number of reasons such as negligence, lack of segregation
at source and absence of devoted system to handle healthcare waste at the facility, absence of
stringent regulatory norms & penalty system and monitoring and evaluation framework.
11. SCAVENGING & RECYCLING
During the field visits to the hospitals, no major scavenging or rag pickers operations were
observed. This is probably due to the fact that the recycling industry in Afghanistan is not
8
very advanced. However, at the major landfill/dumping sites across the country e.g. Gazak
in Kabul, some scavenging & recycling activity does exist.
12. HEALTH CARE WASTE MANAGEMENT PLAN
The preliminary plan concentrated on improving the existing Health Care Waste Management in the
health sector of Afghanistan, focusing on organizational and implementation arrangements, training
and financial implications. The Government of Afghanistan and the MoPH were committed to
undertake a proper sectoral assessment of HCWM and develop a comprehensive HCWMP within the
first six months of SEHAT implementation, which after approval by the WB would replace the
preliminary HCWMP with this comprehensive Healthcare Waste Management Plan.
At the preliminary stage the objective of the plan was to establish the following basic intervention
for health care waste management:
Develop/adopt and disseminate guidelines for the proper management of medical waste to
relevant stakeholders ;
Develop/ adapt and implement a training package for health workers on proper healthcare waste
management;
Increase public awareness and promote community participation in municipal solid waste
management (e.g. reuse, reduce and recycle);
Increase the number of health facility with incinerator;
To monitor the performance and review the Waste Management Plan at least annually;
Based on the situation analysis of HCWM in Afghanistan, the existing practices & status of the
major operations have been detailed to identify the gaps. Based on the identified gaps for different
operations the objectives for the HCWM plan have been worked out and the corresponding plan
activities for the major components have been highlighted below:
Table 2: Gaps and Objectives for HCWM
S.
N
Operations Existing Practices/Status Gap Objectives Plan Activities
1. Waste
Generation Waste Generation not
monitored primarily
because of lack of
proper collection and
segregation
Lack of
monitoring
,weighing
& record
keeping of
HCW
generated at
the HCF
Waste generation
to be monitored
quantitatively as
well as
qualitatively.
Extensive
Reporting
System &
procedures to be
put in place.
Daily reporting
system
suggested for
waste
quantification
& monitoring.
Also monthly
& quarterly
reports.
2. Waste
Collection Waste Collected from
the OT, General Wards,
OPD Lab etc., gets
mixed generally.
Improper
Inadequate
collection of
different
Color-coded
Bins for different
stream of HCW
i.e. Anatomical
Different types
of HCW to be
collected in
color-coded
9
Apart from the sharps &
Placentas, most of the
other waste is collected
Needle-cutters/Hub –
Cutters not used
generally
streams of
HCW
Waste, General
Waste & Sharps
to be provided.
Needle
Cutters/Hub
Cutters to be
used for
separating used
plastic syringes
from needles
sharps
bags & bins as
per the HCWM
Plan
3. Waste
Segregation General Waste,
anatomical waste, &
other Infectious wastes
are normally collected
separately at the point of
generation
Sharps (used AD
syringes) collected
separately in yellow
Boxes, but end up
getting mixed during
transportation.
Patients/Visitors in the
wards sometimes dump
the general waste in the
bins near the Nursing
Stations
Improper
Segregation
of the
Wastes and
mixing of
the
segregated
wastes
during
collection &
transportatio
n
Different types
of HCW to be
segregated at
source through a
clear-cut color
coding system.
Color –coded
Bins to be
provide at
appropriate
locations in the
HCU.
No access to the
patients/visitors
to the Bins
placed near the
Nursing Station
and OT for
collection of
Infectious waste,
Anatomical
Waste & Sharps.
Designated
Color coding
system for
bags, bins,
trolleys &
secondary
storage planned
4. Color
Coding Color-coding exists only
as far as usage of yellow
Boxes for used AD
syringes and Black bins
for other wastes
No Color-Coding for
Bags & the trolleys in
which wastes are
transported
The color-coding for
different types of
HCW is not consistent
and used more as an
exception than as a
rule
Lack of Consistency in
color-coding often results
in different types of HCW
getting mixed
Inconsistenc
y in the
color-coding
for different
types of
HCW
Elaborate but
implementable
Color-coding
mechanism
suggested for
different types of
HCW
Consisted &
Uniform Color-
Coding for
Waste
Collection,
Transportation,
Secondary
Storage etc.
planned.
Consistent color
–coding for
HCW collection,
segregation,
transportation to
secondary
storage &
- Do -
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secondary
storage faculties
to usher in
uniformity and
alienate the
hazards of
mixing of the
waste & thus
ensuring a better
HCWM.
5. Waste
Transportati
on
Primary Waste
Transportation5 in Bags
Carried manually by
trolleys by the Hospital
Sanitation Workers
Secondary
Transportation is non-
existent as the disposal
takes place inside the
HCU primarily.
Unsafe
Primary and
Secondary
Transportati
on
Primary
Transportation in
Bags & Trolleys
with the same
color-codes as
the waste
collection Bins
Secondary Waste
Transportation
in closed
vehicles carrying
HCW symbol
and duly
authorized by
NEPA/Environm
ental Health
Department
Uniform color
coded trolleys
for primary
transportation
of segregated
HCW and
Authorized
vehicles for
secondary
transportation
from Hospitals
to the
Treatment/Disp
osal site
6. Training Most of the Doctors,
Nurses & Para-medical
staff have been trained
in Infection Prevention
as per the Country’s IP
Policy
The training schedule &
re-training as per the IP
Policy is not followed.
Virtually no training
is being done on
HCWM
Re-training
as per the IP
policy is not
done. The
refresher
training is
not provided
as per the
schedule
proposed in
the IP
Policy.
The IP training
procedures &
schedules to be
followed strictly
in accordance
with the IP
policy.
Detailed
Training Plan for
HCWM worked
out covering
different
stakeholders
Training Manual
to be prepared on
HCWM.
Special
emphasis and a
detailed
training plan
based on TNA
provided in the
HCWMP
7. Waste
Managemen
t Committee
No Provision for a
waste Management
committee at HCU level
Focal Person for
HCWM not appointed in
most of the HCUs
No
Institutional
Mechanism
to monitor
& record the
HCWM at
the HCU
level
Detailed Action
Plan&
Guidelines for
forming waste
Management
Committees at
the HCU
recommended.
Plan to include
a responsible
broad based
WMC with a
clearly
designated
Focal Point at
the HCU Level
5 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area
within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage
areas to the Treatment/Disposal Site.
11
Designated Focal
Point for HCWM
at the HCU level
made essential.
for HCWM
8. Secondary
Storage No proper provision for
Secondary Storage of
HCW.
No timeframe
earmarked for
Secondary storage of
HCW before its
disposal.
Improper
Secondary
Storage and
the
maximum
time for
storage/freq
uency of
collection
not defined
The maximum
timeframe for
Secondary
Storage for
different types of
HCW specified.
Provision for a
proper
secondary
storage system
in the hospital
and maximum
time of 48
hours
earmarked for
transportation
to the
treatment/
disposal site.
9. Treatment
& Waste
Disposal
No clear cut policy on
HCW treatment and
disposal
HCW either burnt in
ovens/single chamber
Incinerators or is buried
inside the compound
No disinfection
equipment such as
Microwave/Autoclaves/
Shredders installed
except a few hospitals
Lack of
Policy for
HCWM
measures
and low
quality
equipment
used for
treating
HCW
Policy guidelines
&
Implementation
Plan for HCWM
including
treatment &
disposal
suggested.
Usage of
Double-chamber
Incinerator,
Autoclaves and
shredder with
guidelines for
disposal of
Incinerator ash
Policy
framework on
CWTF
recommended.
Plan to include
technology and
specifications
of HCW
treatment
equipment and
operational
framework for
CWTF
10. Technology No Comparative
evaluation of various
technologies for HCW
treatment has been or is
being done.
A low level of
technology is in use for
HCWM e.g. Single
Chamber Incinerators
ovens, Drums,
Cemented Kilns etc.
Low level of
technology
in use in the
current
HCWM
practices
Comparative
evaluation
undertaken for
alternate
technologies for
different types of
HCW &
appropriate
recommendation
s made
Plan for
technology
adaption in the
local context and
for remote areas
also suggested
Appropriate
technology
guidelines at
various levels
of HCUs
including those
for remote
areas included.
11. Equipment The equipment for
HCW waste collection,
transportation, treatment
& disposal is of poor
Lack of
standardizati
on and
quality
Plan for
procurement,
Commissioning,
Maintenance of
Standards for
HCW treatment
equipment and
the broad
12
quality with no clear set
of guidelines
Non-standardized
equipment is being used
mostly.
specification
s for HCW
treatment
the right type of
equipment
provided.
Broad standards
for each type of
equipment to be
used in HCWM
set &
documented
procurement,
commissions &
maintenance
plan to be
provided.
12. PPE The PPE such as gloves,
goggles, mask boots etc
is used partially in some
of the hospitals.
The guidelines provided
in the IP Policy are also
not followed in general
No mechanism to
monitor the extend of
usage of PPE
Guidelines
for PPE not
fully
followed as
laid down in
the IP policy
Clear-cut
guidelines on
usage of PPE by
various
stakeholders in
HCWM i.e.
Doctors, Nurses,
Para-medical
Staff and
Sanitation
workers
recommended
Strict adherence
to the PPE
recommended in
the IP Policy
recommended
Guidelines &
Framework for
usage of PPE
provided.
Plan to
strengthen PPE
usage as per the
IP Policy as
well as the
regular
monitoring of
the same.
13. Monitoring
&
Evaluation
No M&E mechanism for
HCWM is in place at
HCU level
M&E for HCWM
recently included the
work Profile for the
NGOs under the SEHAT
project in the fresh
bidding process
undertaken in 2013.
Lack of
M&E
mechanism
for HCWM
at the HCU
level
A definite M&E
framework for
HCWM
recommended
M&E by
Independent 3rd
Party
recommended in
addition to the
existing
structures
M&E
framework to
be included in
the Plan with
provision for
3rd
Party
monitoring of
HCWM at
Provincial &
National level
14. Action Plan No road map for
implementing HCWM
Plan in Place at the
Central, Provincial or
the HCU level
Absence of
a road-map
for
implementin
g HCWMP
An Action Plan
suggested for
implementing
HCWM at
various levels
incorporating the
time schedule,
Training Plan
and the costs
Action Plan
with time
schedules,
training, IEC &
financial costs
to be suggested
15. Finance No separate budget for
financing mechanism for
HCWM provided
At the HCW level there
is also no budget for
HCWM provided, not
No a
separate
budget for
HCWM
provided at
the HCU
level.
Financing
Mechanism with
Capital
Expenditure
(Capex) and
Operational
Expenditure
Financial
estimated
Budgets for
both Capital
Expenditure &
Operational
Expenditure for
13
even for operational
costs such as Fuel for
the installed incinerator
(Opex over a 5
year period
provided in the
HCWM Plan.
Investments and
Costs for
separate heads
such as
Procurement of
equipment,
Training, PPE,
Maintenance
detailed.
HCWM to be
provided in the
Plan.
16. PPP PPP in the Health Sector
of providing BPHS &
EPHS through NGOs
has been a success story
by & large
However the same is not
replicated in the HCWM
Sector
PPP in the
HCWM
Sector not
operational
The scope of the
NGOs role to be
enhanced in
training &
capacity building
for HCWM
3rd party M&E
for HCWM
proposed.
Special emphasis
on a new PPP
model for
CWTF, proposed
for HCWM.
PPP role in
HCWM to be
strengthened with a
new CWTF model.
17. Personal
Hygiene &
Sanitation
& Pollution
Abatement
No major focus on
Personal Hygiene such
as washing of hands
PPE etc.
Water Quality at
HCU level & Ambient
Air Quality ( where
Incinerators used) is not
monitored
MoPH
construction
Guidelines
for HCUs
not followed
1) Monitoring
of Water
Quality and
Ambient
Air
including
HVAC
recommend
as per
NEPA
guidelines.
Develop new
construction
guidelines as
well as Plan to
conform with
the same to be
included.
18. Constructio
n Construction
Guidelines for Hospital
buildings exist at MoPH,
but are outdated and not
followed in practice
Need to
implement
stringently
1) Need to
develop
and adhere
to a new set
of
construction
Guidelines
emphasized
Need to include
in M&E
framework
19. Integrated
Holistic
Approach
Piecemeal approach to
HCWM observed at the
HCU level as well as at
the Provincial, Regional
& National Levels
Holistic
Integrated
approach
not followed
for HCWM
1) An
Integrated
approach
with an
inclusion of
various
stakeholder
s in the
HCWM
recommend
14
ed.
20. Capacity
Building of
Env. Health
Department,
MoPH&
other
stakeholders
No Capacity Building
exercise undertaken
Lack of
capacity
among the
various
stakeholders
for
implementin
g HCWMP
1) Specific
actions such
as Exposure
visit to
India.
Orientation
Program on
HCWM for
functional
heads of all
departments
of MoPH
and
extensive
capacity
Building
measures at
the
Provincial
level
recommend
ed
Training and
Capacity
Building,
Exposure/Orien
tation visits
planned under
HCWM Plan.
21. Waste
Water
Treatment
Waste effluent generated
from healthcare facilities
and join the drainage
without treatment
Absence
onsite waste
treatment
system in
HCFs
2) To treat the
wastewater
effluent
generated
from HCFs
before
releasing to
drainage
Provision to
have
wastewater
testing, onsite
treatment,
categorization
of wastewater
from Medical
wards,
Laboratories,
OT, General
Area, OPD etc.
and Healthcare
waste
management
guidelines and
policy
13. ORGANIZATIONAL STRUCTURE
National Level: The responsibility for ensuring the implementation of the HCWMP
lies with the MoPH, which is the implementing agency for the SEHAT. The overall
responsibilities will be with the Secretariat (MoPH). The specific responsibility will be
of the Environmental Health Department under the General Directorate of Preventive
Medicine (GDoPM) of the MoPH. It is important to note that Environmental Health
Department and its designated Focal Officer for HCWMP implementation will work in
consultation with the GCMU on the HCWM activities and act as focal points to ensure
effective, successful implementation of this HCWM plan.
15
Provincial Level: At the provincial level, Provincial Health Directorate (PHD) and
Implementing NGOs will be responsible for the implementation of HCWMP. The
provincial public health director will assign monitoring Focal Point having proper ToR
and will receive needed training for effective implementation of the HCWMP. At the
health facilities, this responsibility will lie with the Head of Health Facility.
District Level: At the district level, the HCWMP implementation, monitoring and
evaluation would be done by the designated focal person for HCWM for that province.
Head of the health facility located at the district center will be responsible for
implementing the Healthcare Waste Management Plan (HCWMP).
The following flowchart depicts the proposed organizational structure for HCWM
system in Afghanistan at the Provincial and National level.
16
Chart 1: Organization structure for HCWM
14. PROPOSED ACTION POINTS TO BE UNDERTAKEN AT VARIOUS LEVELS AS
PART OF THE HCWM PLAN
The below action points to be undertaken at various level have been compiled on the basis
of field visits undertaken at different types of healthcare facilities including BHCs, HSCs,
CHCs in Afghanistan, review of existing policies WHO Guidelines & standards and other
relevant documents.
A. Highlight of major action points to be undertaken as part of HCWM Plan by
MoPH/NEPA 1) Training Kit & Manual (Dari & English versions). A manual would be developed and be
made available to the end user i.e. healthcare facilities as a reference book for the
following:
Setting up of Waste management Committee,
Factors to be considered for the selection of technology
Deputy Minister for Health
Service Provision
General Directorate of
Preventive medicine
Environmental Health
Directorate
Radiation
Protection Wash Environmental
Hygiene Food Safety Admin Training
Health Care Waste
Management
(Staffed with 7 Technical
Officers
Regional HCWM Officer
Provincial HCWM Officer
HCWM Focal Point at each
Hospital
HCWM Focal Point at each
BPHS Health Faculties
17
Color codes to be practiced
Layout specifications for construction of Deep Burial Pits
Safety guidelines to be followed
Manual for Symbols and Labels to be used, routes layout etc.
Sharps Management Plan
B. Highlight of major action points to be undertaken by HCFs
Highlighted key action points have been identified for implementing HCWM Plan at HCFs
including HSCs/BHCs/CHC level are summarized as follows:
1) Formation of Waste Management Committee (WMC)comprising of Heads of the
Hospital, Nursing Superintendent, Doctor/Nurse from Infection Control Committee,
Sanitary Supervisor, Store-in Charge and supervisor of Housekeeping Staff.
2) In-charge Waste Management Committee who also would be the focal point for HCWM
at that facility would be given the responsibility to operate and monitor the management
of the HCW on a daily basis;
3) Standard segregation procedures should be set-up in all Afghan HCFs by implementing a
three bins system that would follow clear cut color coding system , a labeling system as
well as waste minimizing procedures;
4) The development of specific treatment/disposal methods according to the type and the
location of the HCFs where the waste is generated. For example, For the smaller HCFs
and those located in the remote areas with no access with the connectivity, deep burial
pits for both disposal off sharps as well as anatomical wastes would be provided in
conformity with the standard designed as given in the HCWMP.
5) Proper collection points/stores are needed to avoid indiscriminate dumping of the
healthcare wastes in the hospital compound where it contaminates the air and the hospital
environment.
6) An exhaustive Feedback system would be implemented at HCUs on parameters such as
quantity & characterization of HCW, training needs, requirements of HCWM equipment
and materials, future trends etc. This feedback would be used to dovetail and improve the
existing plan further.
The schematic diagram of HCWM Plan to be adopted at HCFs including HSCs/BHCs/CHCs is
presented below.
18
15. Operational Framework
Hospitals and health facility (HSCs/BHCs/CHCs): As per the revised BPHS Package,
2010/1389 the BHC is a facility offering primary outpatient care, immunizations and
Maternal and Newborn care. Services offered include antenatal, delivery, and postpartum
care; newborn Care, nonpermanent contraceptive methods; routine immunizations;
integrated management of childhood illnesses; treatment of malaria and tuberculosis,
including DOTS; and identification, referral, and follow-up care for mental health patients
and persons with disabilities including awareness-raising. The CHC covers a catchment area
of about 30,000–60,000 people and offers a wider range of services than does the BHC. In
addition to assisting normal deliveries, the CHC can handle certain complications, grave
cases of childhood illness, treatment of complicated cases of malaria, and outpatient care for
mental health patients.
Storage Facility: The shortage of storage areas results in the mixture of waste or creation of
overflow which allows animals and scavengers easy access to infectious waste. Another area
of concern is the storage of insecticide stocks for vector control activities at primary
healthcare facilities. This tends to be poor, with insecticides often being stored close to
pharmaceutical stocks or in village houses where spraying operations take place. The
responsibility to supervise the internal collection of wastes, their transportation, availability
of waste bags, protective clothing and collection carts and crews should be given to a
designated officer i.e. the person in-charge of healthcare waste management at the HCF.
Infection Control: It is very important to note and recognize that infection control is the
responsibility of all healthcare professionals – doctors, nurses, pharmacists and others.
Preventing nosocomial infections requires a hygienic and sanitized environment and
maintenance of good practices and use of protective gear. Routine cleaning of the health
facility is absolutely essential, as that will keep the environment free from dust and soil.
19
Spill Control: Spillage usually requires clean up only of the contaminated area. For spillage
of infectious material, however, it is important to determine the type of infectious agent; in
some cases, evacuation of the area may be necessary. Procedures for dealing with spillage
should specify safe handling operation and appropriate protective clothing.
Treatment and Disposal of Health Care Wastes
All HCFs should treat and dispose the medical waste as given below:
All sharps in their puncture proof containers should be disposed in the sharps pit, which
is to be located within the premises of the HCF.
Infected organic waste, after disinfection, should be taken to the onsite deep burial pits
and covered with a layer of lime and soil.
Infected recyclables such as plastics and metals should be first disinfected using bleach
solution and / or autoclaved before sent for recycling.
If there is no organized collection of garbage / municipal solid waste, the general /
communal waste – non-infected - should be managed as follows:
o Organic waste such as kitchen waste and leaf fallings put in a compost pit, which
is to be located within the premises. Standard composting methods such as
mixing the waste with leaf fallings and soil should be done. Compost will be
available within a few days and this should be used for the garden. Care must be
taken to ensure that the organic waste is not infected by segregating the infectious
waste at source.
o Recyclable material such as packaging material and paper should be sold to
authorized recyclers or to link with Municipal Wastes. Care must be taken to
ensure that the recyclable waste is not infected and kept separated from infectious
wastes at all times.
Segregation of Waste and Onsite Storage: Segregation of waste at source is a single
most important step in bio-medical waste management. Once bio-medical waste mixes
with general waste, the waste management problem magnifies and becomes
unmanageable. It is critical that wastes be segregated at the point of generation itself.
Transportation of health care Waste: Medical Wastes have to be transported both within the health facility
and from the facility to the final disposal location. Properly designed carts, trolleys and other wheeled
containers will be used for the transportation of waste inside the facilities. Wheeled containers shall be so
designed that they have no sharp edges. Waste handlers must be provided with uniform, apron, boots, gloves,
and masks, and these should be worn when transporting the waste as described earlier.
Use and Disposal of Auto-Disabled (AD) Syringes
The MoPH recommends that Auto-Disabled (AD) syringes are to be used for
immunization instead of glass or disposable syringes. In parallel to introducing AD
syringes, MoPH has also developed and disseminated detailed user guidelines that
outline steps that should be followed when using an AD syringe and its disposal.
16. AWARENESS AND TRAINING
a) Awareness: Every province should plan and undertake general awareness raising activities
for Infection Monitoring and Environmental Plan (IMEP), which should include all levels of
20
healthcare facilities. All IMEP related awareness activities should be fully integrated with
those being undertaken under the other national health programs. Professional bodies like
health promotion department of MoPH can be involved in enhancing understanding and
promoting good practices. At the health facilities, appropriately located display of IEC
materials is most effective in ensuring that workers follow segregation, treatment and
infection control practices.
b) Public Consultation: It is proposed to have extensive public consultations at various levels
with different stakeholders such as NGOs, Hospital Administrators, Municipalities, Doctors
and other medical staff, elected representatives, community, relevant government ministries
and departments in Afghanistan such as NGOs, Hospital Administrators, Municipalities,
Doctors and other medical staff , elected representatives, community, relevant government
ministries and departments before the proposed HCWM plan is taken up for
implementation. It is also suggested that since the “ownership” by the various stakeholders is
an important criteria for its success, the HCWM plan may be subjected to minor changes &
modifications based on the feedback received during the Public consultations while meeting
the overall Environmental compliance criteria and the World Bank Safeguards.
c) Training:
i. Capacity Building at Central and Provincial Levels: The reinforcement of the
institutional capacity will be done at national and provincial levels through specific
technical training to support the HCFs in implementation of new HCWM policy
ii. Health Workers: The level of awareness among the health workers of the risks of
HCW, Good Practices in HCWM, Correct Procedures etc. is quite low. The HCWM
Concept has not been adequately propagated among the Health workers in general
and their limited awareness is broadly restricted to the Training and procedures
covered in the IP protocol.
Even the prescribed training schedules as per the IP Policy are not followed and a majority of the Health
Workers have not been imparted the updated training on IP. Visits to some of the HCUs located in the
remote/rural areas revealed that the Doctors and the Nursing staff there have not undergone these trainings
for a long period.
The PPHD will be responsible for training of its staff in HCWM plan implementation. There are two
modules for training modules – (i) train-the-trainer and (ii) regular on-going training within the health
facilities. The implementing NGOs will undertake a needs identification to facilitate planning and allocation
of budget for this activity. It is envisaged that all health facilities under intervention areas of the SEHAT
project have officially recognized trained health personnel who will be responsible for health care waste
management. Existing awareness and training materials can be used to further develop the skills for the
sound management of health care wastes. These resources will be available at MoPH and NGOs.
21
I. Introduction
Health care Waste Management consists of solids, liquids, sharps, and laboratory waste that are
potentially infectious or dangerous and are considered bio waste.
It must be properly managed to protect the general public, specifically healthcare and sanitation
workers who are regularly exposed to healthcare waste as an occupational hazard. In hospitals,
medical waste, otherwise known as clinical waste, normally refers to waste products that cannot
be considered general waste, produced from healthcare premises, such as hospitals, clinics,
doctor’s offices, veterinary hospitals and labs.
Health related activities produce a considerable amount of waste on daily basis as a result of
preventive and curative service delivery. The composition of waste produced is in the form of
sharps (needles, syringes), non- sharps, blood and other body fluids being infected and non-
infected, chemicals, pharmaceuticals and medical devises. Health workers, waste handlers, users
of health facilities and the community are all exposed to health-care related waste and ill health
as a result of poor management. A good health-care waste management plan could result in
healthier communities thereby reducing the cost of health-care, as well as creating opportunities
for recycling. A few important principles of sound management of healthcare related waste
include:
Definition of a policy framework;
Assignment of legal responsibility for safe management of waste disposal to the waste
producers;
Allocation of adequate financial resources and cost recovery mechanisms;
High level of awareness on proper waste disposal among all health workers in all cadres, as
well as on part of patients/families/communities, particularly in case of infectious diseases,
such as tuberculosis.
Background of HCWM in Afghanistan:
Since the establishment of a new administration in 2002, the Afghan Government has given the
utmost importance to addressing the high rate of maternal and child mortality, especially in rural
areas. The MoPH undertook a series of critical and strategic steps: it defined a Basic Package of
Health Services (BPHS) and later an Essential Package of Hospital Services (EPHS); it
established a system for contracting on a large scale with international and national non-
governmental organizations (NGOs) for delivery of these services. The Ministry of Public
Health (MoPH) also prioritized monitoring and evaluation of health sector performance.
Through the deployment of predominantly local consultants, the MoPH addressed the human
resource capacity constraints in terms of managing NGO contracts, tracking health sector
progress through rigorous impact level monitoring and performing its stewardship functions
effectively.
The proposed support under System Enhancement for Health Action in Transition (SEHAT)
project in the health sector will ensure provision of basic services in the project area and past
achievements are sustained over time. It will build upon the current support programs of IDA,
ARTF and EU and make these more responsive to the present and future needs of the sector by
focusing on the medium term system development needs of the sector in a sustainable fashion.
With World Bank experience in sector wide and programmatic support, IDA will facilitate and
22
support systems development and realignment of development assistance to the sector and move
towards a sectoral approach so that financing for the sectoral priorities can be better guaranteed
through a well-coordinated effort by development partners.
The mission of the MoPH for health in Afghanistan states that improve the health and nutritional
status of the people in an equitable and sustainable manner through quality health services
provision, advocating for the development of healthy environments and living conditions; and
the promotion of healthy lifestyles.”
SEHAT is proposed as a five year program to be funded through IDA and ARTF. The proposed
project will include support for BPHS and EPHS services in provinces traditionally supported6
by the Bank as well as the 10 provinces currently financially supported by the EU. The project
has two components:
Component 1: sustaining and improving BPHS and EPHS services: the project will support the
implementation of the BPHS and EPHS through Performance- based Partnership Agreements
(PPAs), i.e. contracts between the MoPH and the implementing non- government organizations
(NGOs). It will also support the government’s efforts at delivering the BPHS through contracting
in management services in designated provinces, and implementation of urban BPHS in Kabul
city (the urban BPHS may be extended to other cities). It will include support to improve access
to and quality of BPHS/ EPHS services, and training of additional community midwives and
community nurses. In addition, financing will be made available for marginalized population
such as prisoners and nomads and HIV/AIDS prevention services for targeted population sub-
groups.
Component 2: Building the stewardship capacity of the MoPH and system: a) public hospital
reform and regulation of both public and private provider; b) building regulatory frameworks
and capacity to conduct quality assurance of pharmaceuticals; c) building capacity for effective
health promotion; d) development and testing of innovative financing models for the sector; e)
building/ strengthening human resources management system including appropriate use of
technical assistance, and expanding/ creating training capacity for community midwifery,
community nursing and hospital management; f) strengthening procurement and fiduciary
system, and g) strengthening monitoring and evaluation including surveillance, HMIS, surveys,
operation research, to improve evidence- based decision making. The project will also benefit
from CBR support to the health sector.
Component 3: Strengthening program management (estimated total cost of US$10
million): This component will support and finance cost associated with system
development and stewardship functions of the MOPH
Objective of HCWM Plan: The main objectives of the plan is to identify the most appropriate
management and disposal system for health-care waste management in Afghanistan- appropriate
being defined as environmentally sound, technically feasible, economically viable, and socially
23
acceptable – and to prepare a policy framework and five –year action plan (including both physical
investments and training activities) to put in place and implement this system.
II. Policies, Legislation and Regulation
In Afghanistan, existing Policy Framework which are relevant for Healthcare Waste
Management include:
i) Constitution of the Islamic Republic of Afghanistan
ii) Environmental Law of the Islamic Republic of Afghanistan
iii) National Environment Impact Assessment Policy 2007- Islamic Republic of Afghanistan
iv) MoPH Strategic Plan, 2011
v) National Infection Prevention Control Policy, 2005
vi) World Bank Safeguard Policies
vii) IAEA Safety standards series occupational radiation protection
Environmental Protection Act, 2007
Constitution of the Islamic Republic of Afghanistan: As per the article 15 of the Constitution, the
state is obligated to adopt necessary measures to protect and improve forests as well as the living
Environment which is also relevant for Healthcare Waste management in Afghanistan. Next step
undertaken by the Islamic Republic of Afghanistan is enactment of Environment Protection Act,
2007 as well as establishment of National Environment Protection Agency. Environmental
Protection Act, 2007, Chapter 4 on integrated Pollution control is directly relevant for Health
Care Waste Management issues:
Art 27: Prohibition against discharges
Art 28 : Pollution control licenses
Art 29: Reporting and containing discharges
Art 30: General prohibition and duty of care in relation to waste management
Art 31: Waste Management Licenses
Art 32: Hazardous waste management licenses
National Environment Protection Agency (NEPA), Afghanistan came in existence in 2005 and
was embodied as policy making institutions and regulatory authority in Afghanistan. The
institution draws all power and authority from Environment Act of Islamic Republic of
Afghanistan which was promulgated in the year 2007.
MoPH Strategic Plan
MoPH Strategic Plan (2011-15) developed by the Ministry of Public Health (MoPH) has 8
strategic Directions which also emphasis upon the regulation and standardization of quality health
services, advocate and promote healthy environment.
This advocates for and promotes healthy environments adopting the following strategic
objectives:
24
1. Strategic Objective 1: To strengthen the stewardship role of MoPH in relation to
Environmental Health by developing regulations and clarifying roles and responsibilities
under the Environmental Health program
2. Strategic Objective 2: To advocate for increased availability of safe drinking water in order
to reduce the burden of disease from contaminated water;
3. Strategic Objective 3: To increase food safety practices to prevent food borne illnesses in
food service and retail establishments;
4. Strategic Objective 4: To develop a systematic framework to lead a national process to
reduce air pollution and promote clean air (in collaboration with the Environmental
Protection Agency)
5. Strategic Objective 5: To create a national multispectral radiation protection forum to agree
on and advocate for safe levels of radiation in the country including increasing industry and
public awareness of this issue
6. Strategic Objective 6: To create a national multi-stakeholder mechanism for the
management of garbage and hazardous wastes (including solid waste and healthcare waste)
7. Strategic Objective 7: To improve hygiene and sanitation throughout the country among the
general public and health workers;
8. Strategic Objective 8: To build capacity and improve occupational health and safety among
all workplaces;
Infection Prevention and control Policy, 2005.
The MoPH's National Policy on Infection Prevention and Control for Hospitals and Health
Centers (2005) provide the broad principles of Infection Prevention and control (IPC) for all
Afghanistan healthcare facilities. The procedures manual provides the specific guidelines for
implementation of effective IPC program in the hospitals and health centers. The objectives of the
manual are twofold i.e.
i) To facilitate the implementation of effective implementation of the national IPC policy
ii) To provide the technical guidance necessary for the clinical managers of health facilities to
be able to implement an effective IPC program
The IPC Program covers the Nosocomial Infection Surveillance system, Environmental
Sampling, occupation Health Program and Safe Injection Practices. The IPC for housekeeping,
waste disposal and pest control also has been provided.
World Bank Safeguard Policies
The World Bank classifies the proposed projects into one of the four categories depending on the
type, location, sensitivity, and scale of the project and the nature & magnitude of its potential
environmental impacts. Health Sector Projects are typically classified as Category B (issues are
relatively straightforward & mitigation measures are well-defined & implementable).
In category B, the borrower consults projects affected groups and local NGOs about the projects
environmental aspects and takes their views into account. Some of the desirable features of a
good safeguards management are the following:
25
1) Anticipate Safeguards Consideration early in the project preparation process
2) Design Projects and Project Schedules to avoid downstream problems & delays
3) Assist Borrowers in complying with Safeguards work requirements
Vector Management in Public Health Projects is governed by The World Bank Operational Policy
4.09. The OP and BP apply to all projects involving Vector management, whether or not, the
project finances pesticide under the Pest management policy, the World Bank supports a strategy
that promotes the use of biological or environmental control methods and reduces reliance on
synthetic chemical pesticides used must:
i) have negligible adverse human health effects
ii) be effective against the target species
iii) Have minimal effect on non-target species and the natural environment
iv) Take into account the need to prevent the development of resistance
IAEA Safety Standards Series Occupational Radiation Protection
IAEA Safety Standards Series Occupational Radiation Protection in the Mining & Processing of
Raw materials (Safety Guide No. Rs –G-1.6)
Training in Basic health and Safety in relation to radiation may include the following:
i. The principles of radiation protection (limits and optimization)
ii. Basic quantities and units in radiation protection
iii. The properties of and hazards associated with radioactive materials
iv. The purpose & methods of estimating workers’ radiation does including the use of
individual monitoring & measurements
v. The proper practices to eliminate, limit or control radiation does to workers including
personal hygiene & basic techniques of dose reduction such as shielding, distance & time.
vi. The persons to be contacted on matters of radiation health & safety
vii. The obligations of workers under the regulations issued by the regulatory body
viii. The health effects of radiation exposure
ix. The meaning of warning signs
On assessment of existing policies, enough provisions to deal with the healthcare wastes exist but
the role and responsibility are not clear. It creates ambiguity about the accountability at each level
from regulatory authority to healthcare services facilitators. This makes it imperative that the
country should have a clear cut rules and regulation, guidelines and standards to be maintained,
establishment of linkages between different applicable acts and policies, designation of body, a
waste management committee, functions, clear guidelines on reporting systems and provision of
3rd
Party Monitoring and evaluation. Like other countries, this rule can be christened as
‘Healthcare Waste Management & Handling Rules, Islamic Republic of Afghanistan.
26
Health Care Waste
The World Health Organization (WHO) defines health care waste as total waste generated by
hospitals, health care establishments, and research facilities in the diagnosis, treatment, or
immunization of human beings or animals, and other associated research and services. Hazardous
health care wastes can be categorized into different groups as presented in Table 3.
Hazardous clinical wastes pose risks to individuals exposed to them (both within and outside
establishments), to workers in waste disposal facilities, and scavengers. Potential hazards
associated with these wastes, especially their effects on human health are paramount (Table 4). It
is, therefore, necessary to examine such hazardous wastes from broader perspectives—that is,
from generation to collection, storage, and disposal.
Table 3: Health Care Waste Categories and Descriptions
Waste category Description and examples
Infectious Waste Waste suspected of containing pathogens (e.g., laboratory cultures, waste
from isolation wards, tissues, materials or equipment having been in contact
with infected patients, and excreta)
Pathological Waste Human tissue or fluids (e.g., body parts, blood and other body fluids, and
human fetuses)
Sharps Sharp waste (e.g., needles, infusion sets, scalpels, knives, blades, broken
glasses, etc.)
Pharmaceutical
Waste
Waste containing pharmaceuticals (e.g., expired pharmaceuticals or no
longer needed, contaminated items or containing pharmaceuticals [bottles,
boxes])
Genotoxic Waste Waste containing substances with genotoxic properties (e.g., waste
containing cytotoxic drugs [often used in cancer therapy], genotoxic
chemicals)
Chemical Waste Waste containing discarded chemical substances (e.g., laboratory reagents,
film developer, disinfectants which are expired or no longer needed,
solvents)
Wastes with high
content of heavy
metals
E.g., batteries, broken thermometers, and blood pressure gauges
Pressurized
containers
E.g., gas cylinders, cartridges, and aerosol cans
Radioactive waste Waste containing radioactive substances (e.g., unused liquids from
radiotherapy or laboratory research, contaminated glassware, packages or
absorbent paper, urine and excreta from patients treated or tested with
unsealed radionuclides)
27
Table 4: Health Effects and Potential Hazards from Clinical Wastes
Potential hazards Health effects
Infectious agents Respiratory infections, genital infections, skin infections, Meningitis, AIDS,
Viral Hepatitis A, B, and C
Radioactive Carcinogenic and mutagenic, skin or eye irritation, nausea, headache, or
dermatitis ,Cancer, burn and skin irritation, headache, dizziness, and
vomiting
Sharps Double risk: injury and potential transmission routes for HIV, and Hepatitis
B and C from
contaminated sharp
Pressurized
containers
E.g., gas cylinders, cartridges, and aerosol cans , Injury from explosion
Hazardous
chemicals
Intoxication, burns and skin irritation, pollution of groundwater, surface
water and the air,
possibility of fire, poisoning
Pharmaceuticals Ineffective medical care from the consumption of expired pharmaceuticals,
pollution of
groundwater, surface water, and air
Genotoxic waste E.g., batteries, broken thermometers, and blood pressure gauges
III. Situation analysis of HCWM in Afghanistan and Development of Comprehensive HCWMP
To analyze the present situation of HCW management system in Afghanistan, the following approach &
methodology has been adopted.
i) Desk Research: After undertaking of ToR and preliminary meeting with the concerned
stakeholders, an exhaustive desk research and internet scanning were undertaken to analyze
the present status of the Health Care Waste Management (HCWM) in Afghanistan. The
regulatory provisions and the role of different key stakeholders were also analyzed during
the desk research. Information on the current magnitude of the problems and trends in
HCWM in Afghanistan including generation rates, composition, collection, handling and
disposal techniques etc. were also collected through published materials. The existing Draft
HCWMP was also analyzed during the desk research.
ii) Interaction with Stakeholders: The desk research was followed by one-to one
interaction with the key stakeholders. A sample of Basic Health Centers (BHC) and
Comprehensive Health Centers (CHCs) as well as the regional, provincial and national
level hospitals in Afghanistan were contacted through field survey to assess the Health
care waste generation, current disposal practices, composition of waste ,capacity of the
staff at various levels, Training needs etc.
28
iii) Final HCWM Plan: The said plan will be finalized on receiving a consolidate
comments from the concerned stakeholders such as MoPH, Islamic Republic of
Afghanistan; the World Bank, Afghanistan, WHO, Afghanistan and other (NGOs etc)
Structure of the health care services delivery system:
The structure of the HCS system in Afghanistan is traditional. At the most peripheral level, community
health workers (CHWs) who are non-health professionals with limited but highly targeted training are the
initial point of contact for individuals seeking Health Care Services (HCS). The Basic Health Center (BHC),
a formal structure maintained by the MoPH, is staffed by health professionals and provides, at a minimum,
all of the services that comprise the BPHS. Comprehensive Health Centers (CHCs), the next level of the
system, provides the BPHS and additional services including minor and essential surgery. The District and
Provincial Hospitals offer a broader array of more sophisticated medical care and, at the pinnacle of the HCS
pyramid, tertiary hospitals in the major urban areas provide the most sophisticated care available in
Afghanistan’s public Health and Nutrition Sector. There is a large private and traditional HCS sector in
Afghanistan as well, about which relatively little is known. The MoPH is in the process of developing
regulation and process to fulfill its stewardship role on this aspect of the National HCS as well.
Priority policies:
In line with the Afghanistan Compact of July 2006, the overarching strategic objective of the MoPH is to
obtain nearly universal coverage of a standard BPHS through the Contracting Out initiative and the In 2003
(1382), the MoPH adopted the strategy of contracting out the delivery of the BPHS to non-state providers in
order to be able to concentrate fully on its role as steward of the Health and Nutrition Sector (HNS). The
BPHS is currently being delivered on a contractual basis with NGOs in 31 of the 34 provinces in
Afghanistan. In the remaining three provinces, the MoPH is following a Strategic Management approach by
which it is, essentially, contracting with its own staff, on the same terms as it contracts with NGOs. To
further strengthen and improve the health system in the country, the Essential Package of Hospital Services
(EPHS) was endorsed by the MoPH in July 2005. Now the BPHS and EPHS together represent the basic and
essential elements of the health system in Afghanistan.
Currently there are 2,221 Health facilities nationwide. These can be subdivided into the following categories
or groups:
a. National hospitals=26
b. Regional hospital= 6
c. Provincial hospital= 28
d. District hospital= 75
e. Comprehensive health center=392
f. Basic health center =822
g. Mobile Health Team 103
h. Sub health center = 526
i. Other = 233
29
Because of implementation of the BPHS and the EPHS through the above listed health facilities, a significant
increase in the proportion of the population with access to basic health services has been recorded in the
country. The success of the BPHS is also demonstrated in the significant improvement in key Afghan health
indicators compared with 2003. Some of the achievements of these policies are:
i. By 2009, 75% of the population was covered since the BPHS launched in the year 2003 as
cited by the Health and Nutrition Sector Strategy (HNSS) 2007/08–2012/13.
ii. use of a modern birth spacing/family planning method among married woman increased
from 10% to 20%,
iii. receipt of antenatal care by pregnant woman increased by 60%
This shows that the health indicators have considerably improved. However, the healthcare waste
management system in the BPHS is inadequate in terms of collection, segregation, transportation and
disposal of healthcare waste as well as a lack of institutional mechanism for monitoring and evaluation of the
same. The major reason for this gap has been due to non-availability of funds, lack of awareness and training
at the HCU level.
Development of Comprehensive HCWM Plan
The MoPH developed a Preliminary HCWM Plan for the first 6 months of the SEHAT project in 2012. The
major interventions that were recognized included development and adoption of guidelines for effective
healthcare waste management, creating awareness and training to the end-user/the waste producer/waste
handler.
The preliminary HCWM plan was not purported to cover the following issues in detail:
a. Field study and interactions with the stakeholders
b. Detailed technology evaluation and assessment
c. Technical guidelines & standards to be maintained implementing the plan at the national
and provincial levels
d. Additional policy measures needs to be taken to strengthen the monitoring and evaluation
system,
e. Clear cut reporting system
f. Role & and responsibility for the management of the Healthcare Facilities (HCFs) and
provision of setting up Waste Management Committee (WMC) for effective HCW
management.
g. Level of awareness available among the most vulnerable due to direct contact with the
healthcare waste and associates infection risks such as patients, visitors, nurses, waste
collectors, doctors and management of the healthcare facilities.
h. A comprehensive implementation level healthcare waste management plan
The comprehensive HCWMP document has tried to address the aforesaid issues.
The preliminary HCWM plan was used as the starting point for developing a comprehensive HCWM
Plan by the consultant.
30
The MoPH recruited and international consultant to work on development of a comprehensive healthcare
waste management plan. The Consultant along with the officials from the Environmental Health
Directorate, MoPH undertook field visits in Kabul, Ghazak, Parwan, Panjashir, Balkh etc. and had
detailed Interactions with various stakeholders such as the HCFs( National Hospitals, Regional
Hospitals, Provincial Hospitals, District Hospitals, CHCs, BHCs), International Funding Agencies,
Department of MoPH, NGOs, Landfill Sites, Municipalities, Regulatory bodies, other relevant agencies
etc. Structured Questionnaires were used for eliciting responses from the HCFs in addition to interaction
with the Staff there. For other respondents, unstructured and Semi-structured Questionnaires were used
to get their inputs, in conformity with the objectives of the HCWMP. A copy of the Questionnaire used
for HCFs is provided at Annexure III and the list of contacts undertaken by the consultant during the
course of preparation of the HCWMP is detailed at Annexure IV.
Various Reference documents and articles were perused by the consultant prior to embarking on the field
visits and also during the course of the HCWMP preparation. A partial list of these
publications/documents is provided under the title ‘List of References’.
The inputs from the desk research, and interaction with the stakeholders were useful in assessing the
regulatory framework and its compliance in practice, present status of HCWM at different types of
HCFs, quantities of HCW generated, current technology in use for treatment of HCW and its disposal,
Monitoring & Evaluating mechanism, Training Needs Assessment etc. The specific issues such as
segregation of HCW and color coding practices, type of equipment in use for collection & transportation,
use and disposal of Sharps, development of Landfill facilities for HCW disposal, status of Infection
Control etc. were addressed. The plans for management of HCW from rural areas have been worked out
separately based on the interaction with the various stakeholders. The major lessons learnt during the
interactions with the stakeholders have been highlighted in Table 7 (under the title ‘Existing Waste
Management Practices in Afghanistan’).
These inputs were useful in developing recommendations for the HCWM Plan. A gap analysis was also
undertaken to compare the present status and the recommendations made. The Comprehensive HCWMP
duly incorporates the gap analysis as well as the capacity of the various stakeholders to adopt and
implement the proposed plan.
The plan contains major guidelines to be followed during the implementation stage , provision of pilot
projects for CWTFs, alternate technologies for the remote and rural areas, 3rd
party monitoring and
evaluation framework, format & contents of training programs, procurement policy for major treatment
technologies and safety equipment, construction guidelines for sharp and burial pits etc. apart from other
aspects such as Segregation, Color Coding, Infection Management , Transportation, Disposal, Sharps
Waste Management etc.
Some of the major additional coverage in this Draft Comprehensive Healthcare Waste Management Plan
as compared to the Preliminary HCWM P is as follows:
31
i) Exhaustive field survey in various provinces covering the National Hospitals, Provincial
Hospitals, Regional Hospitals, District Hospitals, CHCs and BHCs levels.
ii) Identifying the Role of various stakeholders for effective implementation of HCWM
Plan.
iii) An overview of the present Infection Prevention and Control Policy, its present status,
implementation issues and its integration into the suggested HCWMP.
iv) The present status of HCWM being practiced in the various HCFs across the country with
regard to HCW collection, transportation, Secondary Storage, Treatment & Disposal
during the implementation of the SEHAT project.
v) The inclusion of HCWM in the agreements/MoUs signed with the NGOs/Implementing
Agencies for effective delivery of health services under the SEHAT projects was also
studied.
vi) Coverage on the new concepts which emerged during the discussions with the
stakeholders e.g. Common Waste Treatment Facility (CWTF ) to have more centralized
facilities for treatment & disposal of Healthcare waste rather than at the individual HCF
level, wherever implementable.
vii) Identifying the roles, objectives & implementation aspects of Waste Management
Committee (WMC) at the HCF level.
viii) A broad Training Need Assessment (TNA) and formulation of training program along
with its cost structure and schedule.
ix) Site Analysis for Centralised Treatment & Disposal of Healthcare Waste management in
the big towns e.g. Kabul.
x) Implementation Schedule for the Healthcare Waste Management Plan along with its
rollout.
xi) Quantification of different types of Healthcare waste at the national level.
xii) Details on Monitoring & Evaluation mechanism to ensure effective implementation of the
healthcare waste management plan
xiii) Alternate models for the Healthcare facilities in the Urban areas and the remotely located
and rural HCFs where accessibility is low.
xiv) Design aspects for the Deep burial pits and the Sharp Pits.
xv) Consistent Color Coding system for collection of various types of HCW and during the
transportation and secondary storages stage as well.
This comprehensive Healthcare Waste Management Plan takes into the account the present status, the
regulatory framework, compliance issues as well as the capacity assessment at the various levels for
implementation of the said plan.
Current Health Care Waste Management Practices in the Afghanistan Health Care Centers:
The generation of MSW in Kabul has gone up exponentially from 300 TPD to 4500 TPD in last 20 years
with the unprecedented rise in the population. Field visits indicate that most of the health facilities are in
relatively good state and appear to be properly maintained by government. Water and sanitation at the health
facilities are poor. Pipe borne water supply facilities (Saripul, Samangan and Balkh) are either only
sparingly functional or do not exist. In the provinces, some wells dry up during the dry season or the water is
32
polluted. Some of the well heads are polluted or wells poorly constructed. Toilet facilities are also either in a
poor state or not functional.
The Incinerators provided at health facilities are made up of local materials (bricks) and have broken down
and need rehabilitation. In a large number of instances traditional ovens rather than incinerators are used for
disposal of wastes. Some new incinerators may have to be constructed urgently too. However, the major
obstacle for improving the HCWM in the country is the lack of proper system from generation to
segregation, collection, transportation, decontamination and disposal in the right and standard manner. There
is no proper color coded bins identified for the collection of the HCWs, no proper collection or temporary
storage rooms and the HCWs are dumped in the open area in the hospitals compounds in many cases even in
the country capital Kabul. However, with the exception of proper disposal of the most hazardous categories
of waste (needles and syringes), there has been steady progress in Afghanistan on an effective, hygienic and
systematic approach to HCWM since the SHARP Project launched. It helped to identify the risk associated
with HCW and need to prepare HCWM Plan for the entire country.
The result of survey7 recently presented also provides information on the precautions and safety measures
interventions related to proper disposal of sharps and use of sterilizers, disinfectants at primary health
facilities as follows:
1. 83.9 % of HFs are using safety boxes or closed containers for disposal of used sharps,
2. Syringes are being disposed without being recapped at the 66.5% of HFs,
3. 37.2% of HFs indicated posted procedures for decontamination procedure steps,
4. Availability of basin with water source and soap disclosed in the 56.7% of HFs
5. Evidence that disinfectants are being used observed at the 66.1 % of HFs,
6. Evidence that the incinerator is being used regularly scored 67.5%,
7. Disposable syringes are being used for all injections, noticed in the 99.7 % of HFs,
8. Evidence for regular use of the sterilizer, found in 70.4% of HFs.
EXISTING WASTE MANAGEMENT PRACTICES
Based on personal interaction with the head of Health facilities, staff, onsite observation, existing waste
management practices in Afghanistan is provided at Table 3.
Table 5: Existing Waste Management Practices in Afghanistan
Operation Existing Practices/Status
Waste Generation Waste Generation not monitored primarily because of lack of
proper collection and segregation
Waste Collection Waste Collected from the OT, General Wards, OPD Lab etc, gets
mixed generally.
Apart from the sharps & Placentas, most of the other waste is
7 –National Health Services Performance Assessment 2011/2012– JHU/IIHMR
33
collected
Needle-cutters/Hub –Cutters not used generally
Waste Segregation General Waste, anatomical waste, & other Infectious wastes are
normally collected separately at the point of generation
Sharps (used AD syringes) collected separately in yellow Boxes,
but end up getting mixed during transportation.
Patients/Visitors in the wards sometimes dump the general waste
in the bins near the Nursing Stations
Color Coding Color-coding exists only as far as usage of yellow Boxes for used
AD syringes and Black bins for other wastes
No Color-Coding for Bags & the trolleys in which wastes are
transported
The color-coding for different types of HCW is not consistent
and used more as an exception than as a rule
Lack of Consistency in color-coding often results in different types of
HCW getting mixed
Waste Transportation Primary Waste Transportation8 in Bags Carried manually by
trolleys by the Hospital Sanitation Workers
Secondary Transportation is non-existent as the disposal takes
place inside the HCU primarily.
Training Most of the Doctors, Nurses & Para-medical staff have been
trained in Infection Prevention as per the Country’s IP Policy
The training schedule & re-training as per the IP Policy is not
followed.
Virtually no training is being done on HCWM
Waste Management
Committee No Provision for a waste Management committee at HCU level
Focal Person for HCWM not appointed in most of the HCUs
Secondary Storage9
No proper provision for Secondary Storage of HCW.
No timeframe earmarked for Secondary storage of HCW before its
disposal.
Treatment & Waste
Disposal No clear cut policy on HCW treatment and disposal
HCW either burnt in ovens/single chamber Incinerators or is
buried inside the compound
No disinfection equipment such as
Microwave/Autoclaves/Shredders installed excepta few hospitals
Technology No Comparative evaluation of various technologies for HCW
treatment has been or is being done.
A low level of technology is in use for HCWM e.g. Single
Chamber Incinerators ovens, Drums, Cemented Kilns etc.
Equipment The equipment for HCW waste collection, transportation,
treatment & disposal is of poor quality with no clear set of
guidelines
8 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area
within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage
areas to the Treatment/Disposal Site. 9 Storage area earmarked within the premises of the healthcare facilities for storage of wastes from different
sources.
34
173.5, 26%
356, 54%
132, 20%
AnatomicalWaste
Waste sharps
Other
Non-standardized equipment is being used mostly.
Personal Protective
Equipment PPE The PPE such as gloves, goggles, mask boots etc is used partially
in some of the hospitals.
The guidelines provided in the IP Policy are also not followed in
general
No mechanism to monitor the extend of usage of PPE
Monitoring & Evaluation NoM&E mechanism for HCWM is in place at HCU level
M&E for HCWM recently included the work Profile for the NGOs
under the SEHAT project in the fresh bidding process undertaken
in 2013.
Action Plan No road map for implementing HCWM Plan in Place at the Central,
Provincial or the HCU level
Finance No separate budget for financing mechanism for HCWM provided
At the HCW level there is also no budget for HCWM provided, not
even for operational costs such as Fuel for the installed incinerator
Public Private Partnership
(PPP PPP in the Health Sector of providing BPHS & EPHS through
NGOs has been a success story by & large
However the same is not replicated in the HCWM Sector
Personal Hygiene &
Sanitation & Pollution
Abatement
No major focus on Personal Hygiene such as washing of hands
PPE etc.
Water Quality at HCU level & Ambient Air Quality ( where
Incinerators used) is not monitored
Construction Construction Guidelines for Hospital buildings exist at MoPH, but
are outdated and not followed in practice
Integrated Holistic
Approach Piecemeal approach to HCWM observed at the HCU level as well
as at the Provincial, Regional & National Levels
Capacity Building of
Env. Health Department,
MoPH& other
stakeholders
No Capacity Building exercise undertaken
Waste Estimate
There are currently 2,221 health facilities comprising of National Hospitals, Regional Hospitals, Provincial
Hospitals, District Hospital, Comprehensive Health Centre,
Basic Health Centre, Sub Health centre and other. The
break-up of these along with wastes generation have been
provided at Table 6.
The estimate of Healthcare waste and the Biomedical Waste
in Afghanistan has been worked out on the basis of
prevailing norms of generation of Anatomical Waste, Sharps
Waste and other Infectious wastes as well as the general
waste. The total HCW generated in Afghanistan is app.150
TPD of which about 27 TPD is the Bio Medical waste and
the rest is the General Waste.
Estimated Waste Composition in Afghanistan
35
Table 6: Illustration of Estimate of Healthcare Waste Generation in Afghanistan
S.N
Type of HCU
App. Nos of
Units in
Afghanistan
Types of HCW Total Annual
Waste of
different
Types (Kg)
Gross total
Waste
Generated
(Tones)
Anatomic
al Waste
Per unit
(kg)
Waste
Sharps
Per
unit
(Kg)
Other
Infectious
Waste incl.
Dressings
Per unit
(kg)
1 National HCU 24 80 160 60 300 7.2
2
Regional
Hospital 6 57 120 42 219 1.3
3
Provincial
Hospital 28 19 40 14 73 2.0
4 District Hospital 69 7 15 7 29 2.0
5
Comprehensive
Health Centre 379 2 5 2 9 3.4
6
Basic Health
Centre 812 1 4 1 6 4.9
7 SHC 472 1 2 1 4 1.9
8 Others 199 6.5 10 5 21.5 4.3
Total 1989
27.0
The HCW generation in Afghanistan has been worked out on the basis of the number of different types of
HCUs and the HCW generated at each of these units from the OPD facilities as well as In house Patients
(please refer Table 7)
36
Table 7: Quantity of HCW in Afghanistan
S.N Type of HCU
Types of Bio-Medical Waste
Anatomical Waste (Kg) Waste Sharps (Kg) Other Infection Wastes (Kg)
Per Bed No. of
Beds
In house
Patients
Waste
OPD Total Per
Bed
No. of Beds Inhouse
Patients
Waste
OPD Total Per Bed No. of Beds In
house
Patients
Waste
OPD Total
1 National HCU 0.15 400 60 20 80 0.2 400 80 80 160 0.1 400 40 20 60
2 Regional Hospital 0.15 300 45 12 57 0.2 300 60 60 120 0.1 300 30 12 42
3 Provincial Hospital 0.15 100 15 4 19 0.2 100 20 20 40 0.1 100 10 4 14
4 District Hospital 0.15 50 5 2 7 0.2 50 10 5 15 0.1 50 5 2 7
5
Comprehensive Health
Centre 0 2 2 0 5 5 0 2 2
6 Basic Health Centre 0 1 1 0 4 4 0 1 1
7 SHC 0 1 1 0 2 2 0 1 1
8 Others(Incl.Pvt Hospitals) 0.15 30 4.5 2 6.5 0.2 30 6 4 10 0.1 30 3 2 5
Source: The HCWM report Estimate
Note: The estimate for the Anatomical Waste, sharps waste & other Infectious waste has been worked out on the basis of the field visits & discussions
with the stakeholders. The smaller HCFs such as BHC & SHC would primarily produce waste from the OPD activities and the sharps waste from the
Immunization drives.
37
The HCWM Plan underlines the fact that the Incinerators have been installed at many
hospitals. However, many of this equipment are not operational owing to a number of factors
such as the following:
1) Lack of trained technicians required to operate the Incinerators
2) Maintenance issues
3) Lack of Funds for the fuel & other operational heads required for their smooth running.
4) Age of the Incinerators
Many of these Incinerators are low technology based, with only a single chamber, low
chimney height (3-4m), no temperature Indicators etc.
The MoPH plans to ensure the already-installed incinerators are made operative. Other option
is to build or De Montfort Incinerator using local material. Periodic air sampling is envisaged
to check the emission standards. The will be done by the third party the result of which will be
presented to the related authority. The other requisite measures include lying down of proper
maintenance procedures training of the technicians and signing of the Annual Maintenance
Contracts (AMCs) with the suppliers of Incinerators so adoption of some good practices with
respect to Incinerators would also ensure a better compliance with the HCWM policy. The
MoPH will undertake corrective measures for those Incinerators not properly located.
Similarly, the issue of disposal of ash from the incinerator will be appropriately addressed.
Disposal Site Analysis
A visit to the Gazak Landfill site revealed that presently the HCW mixed with the MSW is
being disposed off at the site. Aerobic composting of the organic fraction of the MSW is
undertaken. An area of 4000 sqm has been earmarked at the Gazak II landfill site for disposal
of HCW generated in Kabul.
Scavenging & Recycling
During the field visits to the hospitals, no major scavenging or rag pickers operations were
observed. This is probably due to the fact that the recycling industry based on the waste
generated in the healthcare facilities in Afghanistan is not organized; however, a few recycling
operation is going on. there are evidence of scavenging operations, but that is mostly for
municipal waste.
The proposed HCWM policy with focus on implementation of CWTFs in some pilot projects
would lead to generation of reasonable quantities of recyclable material, specially the
Disinfected & treated plastics. The economies of Scale provided by the large scale generation
of the recyclable plastics could be used as an incentive & impetus to the recycling industry,
38
particularly when coupled with the implementation of Segregation of Municipal Solid Waste
at the Landfill site.
Training Needs Assessment
A broad TNA was carried out for Infection Prevention at the National, Provincial & Regional
Hospitals and the Smaller HCUs at the district level and rural areas. A similar analysis was
undertaken for TNA for HCWM at different levels of the Health Care Facilities.
The status of staff training in Infection Prevention based on a scale of non-existent (0) to very
high (5) among various parameters such as the awareness level, initial training and capacity
Building & Retraining as per the IP Policy of the MoPH has been presented in Table ??. A
distinct difference was observed in the status of Training of the staff working at the larger
hospitals and the smaller/rural HCUs.
A similar broad assessment was also made for the HCWM and it was found to be virtually
non-existent (0) to very low (1) in terms of different parameters.
Table 8: Training Needs Assessment
S. No. Policy Awareness
Level
Initial
Training
Capacity
building and
Re-training
1. Infection Prevention
(National, Provincial and
Regional Hospital)
Yes 4 3 1
2. Infection Prevention (District
Hospitals, Smaller HCUs)
Yes 2 2 0
3. Healthcare Waste
Management
(National, Provincial and
Regional Hospital)
No 1 0 0
4. Health Care Waste
Management (District
Hospitals, Smaller HCUs)
No 1 0 0
IV. Health Care Waste Management Plan
The expected outcome of SEHAT project is to contribute to a healthier population and increased
human capital by enhancing the use of a set of health nutrition and population services with
proven cost effectiveness in the country but this may also create adverse impact on environment
and on health if a proper Healthcare Waste Management System is not put in place. Possible
adverse environmental impacts are related to operation and are the following: (a) Disposal of
medical waste, e.g., sharps, human tissues, blood and laboratory waste; and, (b) Risk associated
with handling Health Care Wastes during operation. All these potential environmental impacts
39
could be managed during the operation of the Health Care Facilities and hospitals if a proper
HCWMP is prepared and appropriately implemented.
Keeping in view the above fact, under the SEHAT project, a preliminary plan were prepared to
improve the existing Health Care Waste Management system in the country , focusing on
organizational and implementation arrangements, training and financial implications. The
Government of Afghanistan and the MoPH were committed to undertake a proper sectoral
assessment of HCWM and develop a comprehensive HCWMP within the first six months of
SEHAT implementation, which after approval by the WB would replace the current preliminary
HCWMP.
The objective of the preliminary HCWM Plan was to establish the following basic intervention
for health care waste management:
Develop/adopt and disseminate guidelines for the proper management of medical waste to
relevant stakeholders ;
Develop/ adapt and implement a training package for health workers on proper healthcare
waste management;
Increase public awareness and promote community participation in municipal solid waste
management (e.g. reuse, reduce and recycle);
Increase the number of health facility with incinerators or other environment friendly
technology /equipment
To monitor the performance and review the Waste Management Plan at least annually;
This comprehensive Health Care Waste Management Plan is developed based on what already
agreed in the Preliminary Health Care Waste Management Plan. Based on the work undertaken,
priority interventions for the health care waste management in Afghanistan include:
i) Development of a Manual & Guidelines along with compendium of best practices being
adopted in developed or developing countries on Health Care Waste Management and
dissemination of the same among the stakeholders, end users etc.
ii) Policy education and awareness
iii) Training of the Trainer and Exposure Visits of the Regulatory Authorities
iv) Formulation of Waste Committee at different levels, Determination of Role and
Responsibility
v) Evaluation & determination of technology
vi) Establishment of Common Treatment Facility as Pilot project
vii) Establishment of a new policy framework to facilitate the implementation of the prepared
HCWMP.
viii) Preparing the roadmap for ensuring the involvement of the different stakeholders in
implementation of the HCWMP.
Based on the situation analysis of HCWM in Afghanistan, the existing practices & status of the
major operations have been detailed to identify the gaps. Based on the identified gaps for
different operations the objectives for the HCWM plan have been worked out and the
corresponding plan activities for the major components have been highlighted in the adjoining
Table 9.
40
Table 9: HCWM Plan Activities of Major Components
S.N Operations Existing Practices/Status Gap Objectives Plan Activities
1 Waste
Generation Waste Generation not monitored
primarily because of lack of
proper collection and segregation
Lack of
monitoring
,weighing &
record keeping of
HCW generated at
the HCF
Waste generation to be
monitored quantitatively as
well as qualitatively.
Extensive Reporting
System & procedures to be
put in place.
Daily reporting system
suggested for waste
quantification &
monitoring. Also
monthly & quarterly
reports.
2 Waste
Collection Waste Collected from the OT,
General Wards, OPD Lab etc,
gets mixed generally.
Apart from the sharps &
Placentas, most of the other
waste is collected
Needle-cutters/Hub –Cutters not
used generally
Improper
Inadequate
collection of
different streams
of HCW
Color-coded Bins for
different stream of HCW
i.e. Anatomical Waste,
General Waste & Sharps to
be provided.
Needle Cutters/Hub
Cutters to be used for
separating used plastic
syringes from needles
sharps
Different types of HCW
to be collected in color-
coded bags & bins as per
the HCWM Plan
3 Waste
Segregation General Waste, anatomical
waste, & other Infectious wastes
are normally collected separately
at the point of generation
Sharps (used AD syringes)
collected separately in yellow
Boxes, but end up getting mixed
during transportation.
Patients/Visitors in the wards
sometimes dump the general
waste in the bins near the
Nursing Stations
Improper
Segregation of the
Wastes and mixing
of the segregated
wastes during
collection &
transportation
Different types of HCW to
be segregated at source
through a clear-cut color
coding system.
Color –coded Bins to be
provide at appropriate
locations in the HCU.
No access to the
patients/visitors to the Bins
placed near the Nursing
Station and OT for
collection of Infectious
waste, Anatomical Waste
& Sharps.
Designated Color coding
system for bags, bins,
trolleys & secondary
storage planned
4 Color Coding Color-coding exists only as far
as usage of yellow Boxes for
used AD syringes and Black bins
for other wastes
No Color-Coding for Bags &
the trolleys in which wastes are
Inconsistency in
the color-coding
for different types
of HCW
Elaborate but
implementable Color-
coding mechanism
suggested for different
types of HCW
Consisted & Uniform
- Do -
41
transported
The color-coding for different
types of HCW is not
consistent and used more as an
exception than as a rule
Lack of Consistency in color-coding
often results in different types of
HCW getting mixed
Color-Coding for Waste
Collection, Transportation,
Secondary Storage etc.
planned.
Consistent color –coding
for HCW collection,
segregation, transportation
to secondary storage &
secondary storage faculties
to usher in uniformity and
alienate the hazards of
mixing of the waste & thus
ensuring a better HCWM.
5 Waste
Transportation Primary Waste Transportation
10
in Bags Carried manually by
trolleys by the Hospital
Sanitation Workers
Secondary Transportation is
non-existent as the disposal takes
place inside the HCU primarily.
Unsafe Primary
and Secondary
Transportation
Primary Transportation in
Bags & Trolleys with the
same color-codes as the
waste collection Bins
Secondary Waste
Transportation in closed
vehicles carrying HCW
symbol and duly
authorized by
NEPA/Environmental
Health Department
Unform color coded
trolleys for primary
transportation of
segregated HCW and
Authorised vehicles for
secondary transportation
from Hospitals to the
Treatment/Disposal site
6 Training Most of the Doctors, Nurses &
Para-medical staffhave been
trained in Infection Prevention as
per the Country’s IP Policy
The training schedule & re-
training as per the IP Policy is
not followed.
Virtually no training is being
done on HCWM
Re-training as per
the IP policy is not
done. The
refresher training
is not provided as
per the schedule
proposed in the IP
Policy.
The IP training procedures
& schedules to be followed
strictly in accordance with
the IP policy.
Detailed Training Plan for
HCWM worked out
covering different
stakeholders
Training Manual to be
prepared on HCWM.
Special emphasis and a
detailed training plan
based on TNA provided
in the HCWMP
10 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area within the healthcare facilities; Secondary
Transportation is the process of moving wastes from the secondary storage areas to the Treatment/Disposal Site.
42
7 Waste
Management
Committee
No Provision for a waste
Management committee at HCU
level
Focal Person for HCWM not
appointed in most of the HCUs
No Institutional
Mechanism to
monitor & record
the HCWM at the
HCU level
Detailed Action Plan&
Guidelines for forming
waste Management
Committees at the HCU
recommended.
Designated Focal Point for
HCWM at the HCU level
made essential.
Plan to include a
responsible broad based
WMC with a clearly
designated Focal Point
at the HCU Level for
HCWM
8 Secondary
Storage No proper provision for
Secondary Storage of HCW.
No timeframe earmarked for
Secondary storage of HCW
before its disposal.
Improper
Secondary Storage
and the maximum
time for
storage/frequency
of collection not
defined
The maximum timeframe
for Secondary Storage for
different types of HCW
specified.
Provision for a proper
secondary storage
system in the hospital
and maximum time of
48 hours earmarked for
transportation to the
treatment/ disposal site.
9 Treatment &
Waste Disposal No clear cut policy on HCW
treatment and disposal
HCW either burnt in ovens/single
chamber Incinerators or is buried
inside the compound
No disinfection equipment
such as
Microwave/Autoclaves/Shredder
s installed except a few hospitals
Lack of Policy for
HCWM measures
and low quality
equipment used
for treating HCW
Policy guidelines &
Implementation Plan for
HCWM including
treatment & disposal
suggested.
Usage of Double-chamber
Incinerator, Autoclaves and
shredder with guidelines
for disposal of Incinerator
ash
Policy framework on
CWTF recommended.
Plan to include
technology and
specifications of HCW
treatment equipment and
operational framework
for CWTF
10 Technology No Comparative evaluation of
various technologies for HCW
treatment has been or is being
done.
A low level of technology is
in use for HCWM e.g. Single
Chamber Incinerators ovens,
Drums, Cemented Kilns etc.
Low level of
technology in use
in the current
HCWM practices
Comparative evaluation
undertaken for alternate
technologies for different
types of HCW &
appropriate
recommendations made
Plan for technology
adaption in the local
context and for remote
areas also suggested
Appropriate technology
guidelines at various
levels of HCUs
including those for
remote areas included.
11 Equipment The equipment for HCW waste
collection, transportation,
Lack of
standardization
Plan for procurement,
Commissioning,
Standards for HCW
treatment equipment and
43
treatment & disposal is of poor
quality with no clear set of
guidelines
Non-standardized equipment
is being used mostly.
and quality
specifications for
HCW treatment
Maintenance of the right
type of equipment
provided.
Broad standards for each
type of equipment to be
used in HCWM set &
documented
the broad procurement,
commissions &
maintenance plan to be
provided.
12 PPE The PPE such as gloves, goggles,
mask boots etc is used partially in
some of the hospitals.
The guidelines provided in the IP
Policy are also not followed in
general
No mechanism to monitor the
extend of usage of PPE
Guidelines for
PPE not fully
followed as laid
down in the IP
policy
Clear-cut guidelines on
usage of PPE by various
stakeholders in HCWM i.e.
Doctors, Nurses, Para-
medical Staff and
Sanitation workers
recommended
Strict adherence to the PPE
recommended in the IP
Policy recommended
Guidelines & Framework
for usage of PPE provided.
Plan to strengthen PPE
usage as per the IP
Policy as well as the
regular monitoring of
the same.
13 Monitoring &
Evaluation NoM&E mechanism for HCWM
is in place at HCU level M&E for HCWM recently
included the work Profile for
the NGOs under the SEHAT
project in the fresh bidding
process undertaken in 2013.
Lack of M&E
mechanism for
HCWM at the
HCU level
A definite M&E
framework for HCWM
recommended
M&E by Independent 3rd
Party recommended in
addition to the existing
structures
M&E framework to be
included in the Plan
with provision for 3rd
Party monitoring of
HCWM at Provincial &
National level
14 Action Plan No road map for implementing
HCWM Plan in Place at the
Central, Provincial or the HCU
level
Absence of a road-
map for
implementing
HCWMP
An Action Plan suggested
for implementing HCWM
at various levels
incorporating the time
schedule, Training Plan
and the costs
Action Plan with time
schedules, training, IEC
& financial costs to be
suggested
15 Finance No separate budget for financing
mechanism for HCWM provided
At the HCW level there is also no
budget for HCWM provided, not
even for operational costs such as
Fuel for the installed incinerator
No a separate
budget for HCWM
provided at the
HCU level.
Financing Mechanism with
Capital Expenditure
(Capex) and Operational
Expenditure (Opex over a
5 year period provided in
the HCWM Plan.
Financial estimated
Budgets for both Capital
Expenditure &
Operational Expenditure
for HCWM to be
provided in the Plan.
44
Investments and Costs for
separate heads such as
Procurement of equipment,
Training, PPE,
Maintenance detailed.
16 PPP PPP in the Health Sector of
providing BPHS & EPHS
through NGOs has been a
success story by & large
However the same is not
replicated in the HCWM Sector
PPP in the HCWM
Sector not
operational
The scope of the NGOs
role to be enhanced in
training & capacity
building for HCWM
3rd party M&E for HCWM
proposed.
Special emphasis on a new
PPP model for CWTF,
proposed for HCWM.
PPP role in HCWM to be
strengthened with a new
CWTF model.
17 Personal
Hygiene &
Sanitation &
Pollution
Abatement
No major focus on Personal
Hygiene such as washing of
hands PPE etc.
Water Quality at HCU level
& Ambient Air Quality ( where
Incinerators used) is not
monitored
MoPH
construction
Guidelines for
HCUs not
followed
2) Monitoring of Water
Quality and Ambient
Air including HVAC
recommend as per
NEPA guidelines.
Develop new
construction guidelines
as well as Plan to
conform with the same
to be included.
18 Construction Construction Guidelines for
Hospital buildings exist at
MoPH, but are outdated and not
followed in practice
Need to
implement
stringently
2) Need to develop and
adhere to a new set of
construction
Guidelines
emphasized
Need to include in M&E
framework
19 Integrated
Holistic
Approach
Piecemeal approach to HCWM
observed at the HCU level as
well as at the Provincial,
Regional & National Levels
Holistic Integrated
approach not
followed for
HCWM
2) An Integrated
approach with an
inclusion of various
stakeholders in the
HCWM
recommended.
20 Capacity
Building of
Env. Health
Department,
MoPH& other
stakeholders
No Capacity Building exercise
undertaken Lack of capacity
among the various
stakeholders for
implementing
HCWMP
3) Specific actions such
as Exposure visit to
India. Orientation
Program on HCWM
for functional heads
of all departments of
Training and Capacity
Building,
Exposure/Orientation
visits planned under
HCWM Plan.
45
MoPH and extensive
capacity Building
measures at the
Provincial level
recommended
21 Waste Water
Treatment Waste effluent generated from
healthcare facilities and join the
drainage without treatment
Absence onsite
waste treatment
system in HCFs
4) To treat the
wastewater effluent
generated from HCFs
before releasing to
drainage
Provision to have
wastewater testing,
onsite treatment,
categorization of
wastewater from
Medical wards,
Laboratories, OT,
General Area, OPD etc.
and Healthcare waste
management guidelines
and policy
46
There are three basic operations involved in healthcare waste management i.e. Segregation,
collection & transportation and treatment and disposal. The standard operation guidelines are
already well documented and published at WHO website. The objective of compilation of
different guidelines is to provide a ready reference for the implementing agency/authority during
implementation of HCWM Plan.
a. Waste Segregation Guidelines
Waste Segregation is the process of separating different types of waste at the point of production
and keeping them isolated, so that collection of different types of waste become an easy and safe
affairs of waste handling operations from point of production to disposal of the treated waste.
This could be easily done by following recommended color codes(see Table 8).
Table 10: Recommended Color Codes
S.No. Yellow Bins and Bags Red Bins and Bags Black Bins
and Bags
White Puncture
proof containers
1. Human tissues, Body
parts, organs , sputum
Infectious Solid
Waste(Waste generated
from disposable items
other than the waste
sharps such as Tubing,
Hand-gloves, saline
bottles with IV Tubes,
catheters, glass,
intravenous sets etc.
Food articles Waste Sharps
(Needles, blades,
glass, scalpels etc.
that may cause
puncture and cuts
including both used
and unused sharps
2. Animal Tissues, organs,
body parts, carcasses,
bleeding parts, fluid,
blood and experimental
animals used in research,
discharge from
hospitals, animal houses.
Chemical
Waste(Chemicals used
in production of
biological toxins,
disinfectants,
Insecticides etc.)
Plastic bottles
for soft drinks,
juices etc.
3. Microbiological and
Biotechnology Waste
and other Laboratory
Waste(Waste from
clinical samples,
pathology, bio-
chemistry, hematology ,
blood-bank, lab cultures,
stocks or specimens of
microorganisms, live or
attenuated vaccines,
dishes used for transfer
of cultures etc)
Used Plastic syringes
after hub-cutting/needle-
cutting operations
Aluminum
and metal cans
used for food
and drinks
4. Discarded Medicines
and Cytotoxic Drugs
Paper and
Board
5. Soiled Waste(Items Other
47
contaminated with blood
and body fluids
including cotton,
dressings ,soiled plaster-
carts, linen, bedding,
other materials
contaminated with
blood)
packaging
material
General Waste containers should be placed beside infectious waste containers helps in better
segregation. Color code of bins and bags should be maintained in uniform manner to avoid any
confusion. Proper Label and Symbols must be displayed on bins and bags as per the standard
guidelines of WHO. “Guidelines for the Safe Transport of Infectious Substances and
Diagnostic Specimens by WHO” is available on web for ready reference.
Apart from the color code for the health care waste, the following practices should be
adopted:
i) Residuals of the general health care waste should join the stream of domestic refuse or
municipal solid Waste for proper waste management
ii) Sharp should all be collected together, regardless of whether or not they are
contaminated. Containers should be puncture proof and fitted with covers. It should be
rigid and impermeable to contain not only the sharps but also any residual liquids from
syringes.
iii) Bags and containers for infectious waste should be marked with the international
infectious substance symbol.
iv) Cytotoxic waste, most of which is produce in major hospital or research facilities, should
be collected in leak proof and strong containers clearly marked “Cytotoxic Wastes”
v) Radioactive Waste should be segregated according to its physical form; solid & liquid
and according to its half-life or potency: Short –live and lived in especially marked
containers
b. Storage Guidelines
It is essential to have a designated storage location within the health care establishment. For
storage of healthcare waste the recommended color coding techniques needs to be practiced
thoroughly so that mix up of different kinds of wastes can be avoided. While earmarking and
selecting the storage areas for healthcare wastes the following guidelines should be followed up:
Storage: An impermeable, hard-standing floor with good drainage, and an adequate water
supply to clean and easy to disinfect;
Good lighting and at least passive ventilation and protection from the sun;
Storage area should not be situated proximate to fresh food stores or food preparation areas;
and
Supply of cleaning equipment, protective clothing, and waste bags or containers should be
located conveniently close to the storage area.
48
It should also be ensured that storage times for healthcare waste (i.e. the delay between
production and treatment), unless a refrigerated storage room is available, should not exceed the
following:
Temperature Climate : 72 hours in winter
48 hours in summer
Warm Climate : 48 hours during the cool season
24 hours during the hot season
c. Collection & Transportation Guidelines
To define the collection system it is necessary to understand the basic steps of Health Care Waste
Management Handling System. The basic steps in Health care waste Management handling
evolves on Segregation, Collection & Transportation and Treatment and Disposal.
Collection System can be divided under:
Primary Collection: On-Site Collection(Within the Establishment)
Secondary Collection : Off-site Collection (to CWTFs)
Primary collection starts at the point of waste production. The major waste production points in a
typical healthcare Facility include Medical Wards, Labour Room, OT & Surgical Room,
Pharmaceutical Stores and Labs. The following needs to be practiced:
Nurses and Staff should ensure that waste bags are tightly closed or sealed when they are
about three-quarters full.
Light-gauge bags can be closed by tying the neck but heavier gauge bags would require
plastic sealing tag of the self-locking type. Bags should not be closed by stapling.
Sealed Sharp containers should not be placed in a labeled, yellow infectious health care
waste bags.
The frequency of the collection should be on room to room basis once in every shift and
an ideal time of collection should be the start of every shift.
Strictly followed and practiced the color code guidelines.
The collection practices should be designed in a manner that facilitate the movement of
waste from point of production to storage/ treatment point efficiently while minimizing
the risk of personnel.
Proper training should be given to the contractors or the hospital workers. The driver of
the vehicle should be knowledgeable of medical waste and the measures to be taken in
case of an accidental spillage.
On Site Transportation
Transportation of Waste within the HCFs could utilize wheeled trolleys, containers or carts that
are dedicated solely for the purpose.
The selection of on-site vehicle should be based on the following specifications
49
1. Easy to load and unload
2. No Sharp Edges that could damage waste bags or containers during loading and unloading
and,
3. easy to clean
The sample vehicles for this purpose have been illustrated at Figure 2.
Figure 1: Sample Wheeled Vehicles (Source: WHO)
Off-Site Collection and Transportation of Health Care Waste: The healthcare Waste
generator should be responsible for safe packaging and adequate labeling of waste to be
transported off-site for treatment and disposal. Packaging and labeling should comply with the
guidelines for the Safe Transport of Infectious Substances and Diagnostic Specimens provided by
WHO. Figure 3 is symbol of International Infection Substance used to denote that vehicle is
carrying Healthcare waste or bio-hazardous waste.
It should be the responsibility of waste generator to ensure that waste are being treated and
disposed of properly as per the guidelines of Health Care Waste Management Plan and to the
authorized disposal facility.
The waste should be transported off-site only by the authorized or accredited transporter or carrier
by NEPA.
Special packaging requirements for off-site transport in general, the waste should be packaged
according to the recommendations provided in sealed bags or containers to prevent spilling
during handling and transportation. All waste bags or containers should be labeled with basic
information on their content and on the waste producer. This information may be written directly
on the bag or container or on preprinted labels, securely attached. For health care wastes, the
Figure 2: International Infection Substance Symbol
50
following additional information should be marked on the label: waste category, date of
collection, place in hospital where produced (e.g. ward), and waste destination.
Any vehicle used to transport health care waste should fulfill the following design criteria:
The body of the vehicle
should be of a suitable size
commensurate with the
design of the vehicle, with
an internal body height of
2.2 meters.
There should be a bulkhead
between the driver’s cabin
and the vehicle body, which
is designed to retain the
load if the vehicle is
involved in a collision.
There should be a suitable
system for securing the load during transport.
Empty plastic bags, suitable protective clothing, cleaning equipment, tools, and
disinfectant, together with special kits for dealing with liquid spills, should be carried in a
separate compartment in the vehicle.
The internal finish of the vehicle should allow it to be steam cleaned, and the internal
angles should be rounded.
The vehicle should be marked with the name and address of the waste carrier.
The international hazard sign should be displayed on the vehicle or container as well as
an emergency telephone number.
Further based on different activities related to healthcare services, potential major impacts/issues
because of nature of wastes generated out of these activities, mitigation measures, indicators, cost
implication to initiate mitigation measures , responsibility for mitigation and supervision and
responsibility for monitoring have been worked out in Table 11.
Table 11: Health Care Waste Management guidelines (HCWMP) Matrix for SEHAT
Activities Potential
Major
Impacts/issues
Mitigation
Measures
Indicators Budges $
(Proposed)
Responsibility
for Mitigation
and supervision
Responsibility
for
Monitoring
51
Antenatal
care
Immunization
Laboratory
test
Laboratory
waste, sharps,
syringes, poor
antenatal care.
Risk of
Infection
Sharps
should be
placed in
special
containers
and
properly
labeled
before
incineration
waste
disposal)
Implement
guidelines
and
followed
good health
care
practiced.
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept.
GCMU/
Provincial
public health
directorate
third party/
M&E
department/JH
University
Delivery and
pre-natal
care.
Handling
human parts,
immunization
Risk of cross
infection if no
proper
handling of
waste
including
human parts,
waste water,
and sharps
disposables.
Contamination
of Soils &
groundwater.
Sharps
should be
placed in
special
containers
and
properly
labeled
before
incineration
waste
disposal
Human
parts should
be
disinfected
before
disposal.
Implement
guidelines
and
followed
good health
care
practiced.
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept.
Provincial
public health
directorate
third part/
M&E
department/JH
University
Postnatal
Care
Immunization
Sharps,
disposables
Sharps
should be
placed in
special
containers
and
properly
labeled
before
incineration
waste
disposal
Implement
guidelines
and
followed
good health
care
practiced
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept.
GCMU/
Provincial
public health
directorate
third part/
M&E
department/JH
University
Family
planning
Risk of cross
contamination,
Sharps
should be
Implement
guidelines
Not
Implementing
NGOs/
GCMU/
Provincial
52
laboratory
test,
injections
sharps,
disposables
placed in
special
containers
and
Properly
labeled
before
incineration
waste
disposal
and
followed
good health
care
practiced.
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Environmental
Health Dept.
public health
directorate
third party/
M&E
department/JH
University
Care of the
newborn.
Immunization
Risk of
accidental
infection
through poor
handling of
sharps and
cross
infections
Sharps
should be
placed in
special
containers
and
properly
labeled
before
incineration
waste
disposal
Implement
guidelines
and
Followed
good health
care
practiced
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept
GCMU/
Provincial
public health
directorate
third part/
M&E
department/JH
University
Storage of
Medical
Waste
Risk to
unauthorized
persons and
workers if not
in proper
receptacles,
and workers
not properly
protected.
Proper
handling
and storage
including
protective
gear
according to
HCWMP
Implement
guidelines
and
followed
good health
care
practiced.
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept
GCMU/
Provincial
public health
directorate
third part/
M&E
department/JH
University
Transport of
waste to
disposal sites
Risk of spread
of diseases,
personnel
exposure to
disease and
bacteria
Collect
waste in
closed
containers
and
transport
waste in
specialized
closed
vehicles
Regular
supervision
of
transporters
potters,
verify the
use of
special
containers
for MW,
provide
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
Implementing
NGOs/
Environmental
Health Dept
GCMU/
Provincial
public health
directorate
third part/
M&E
department/JH
University
53
training for
potters
services
Disposal at
site
Incinerator
Impact
(Smoke, flue
gas, lung
diseases)
Proper
siting of
well
construct,
Incinerators,
ash buried
in special
lined pits.
Implement
guidelines
and
followed
good health
care
practiced.
Not
significant
cost, this cost
will be
part of
implementing
NGOs budget
contracting
for delivery
of health
services
Implementing
NGOs/
Environmental
Health Dept
GCMU/
Provincial
public health
directorate
third part/
M&E
department/JH
University
Source: HCWM Preliminary Plan
d. End Disposal Plan for HCWM
End disposal of HCW according to the category/type of wastes can be decided using following
option..
Table 12: Categories of health-care waste and their final disposal decision matrix
Type of Waste Location In-situ
Treatment
End Treatment Final
Disposal
CWTF
CWTF No CWTF
Human tissue, body
parts and placenta`
OT, Labor
Rooms, Wards
Incineration at Common
treatment facility
Deep Burial
inside the
hospital
Incineration
ash to be
buried in
secured
landfill
Cotton, gauze
dressings, POPs soiled
with blood, pus and
other human discharges
All wards, OT,
Labor rooms, Lab
ICU, Acute
wards, Isolation
wards
Autoclave/Microwave
and shredding at
common treatment
facility
Landfilling
after
disinfection
and
converting
them into
pieces
All types of plastics,
i.e. plastic syringes, I.V
lines, I.V bottles, bags
All wards and
departments
Autoclave/microwave
and shredding at
common treatment
facility
Disinfection
and
mutilation
Formal
recycling
Discarded medicines
cytotoxic drugs and
heavy chemicals
Stores Incineration at common
treatment facility
Deep burial Secured
landfilling of
Incineration
54
ash
Soiled Linen OT, labor rooms,
ICU, Isolation
wards, Acute
wards and other
wards
1%
Hypochlorite
solution for 30
minutes
Washed in laundry Washed in
laundry
Reused after
wash
General waste such as
leftover food in
patients plates,
stationery, fruit waste,
unsoiled dressings,
gauze and cotton from
Green bucket
All wards &
departments
Non treatment Municipal
sanitary
landfilling of
the general
waste
NA
Needles, blades All wards &
departments
1%
hypochlorite
for 30 minutes
Stored in Puncture Proof
Containers
Autoclaved
and stored in
Puncture
proof
containers
Formal
recycling after
disinfection
Microbiological
samples
Labs 5%
Hypochlorite
solution for 30
minutes
Autoclaving Autoclaving Liquid
discarded in
drainage
Liquid waste from
wards, departments and
autopsy room
All
wards/Autopsy
rooms
5%
Hypochlorite
for 30 minutes
- - Liquid
discarded in
drainage
Silver nitrate from X –
Ray dept.
X- Ray Dept. - - - Formal
recycling
Broken thermometers
and
sphygmomanometers
All wards &
departments
Collected
safely in
mercury spill
kits
- - Hazardous
land filling
Chemicals used in
production of
biological, used in
disinfection or as
insecticides
Hospital Stores - Send for incineration or
secured landfilling
- Send for
incineration
or secured
landfilling
Discarded expired
infected blood or its
products
Blood Bank 5%
hypochlorite
solution for 30
minutes
Autoclaved at common
treatment facility
Liquid
discarded in
drainage after
disinfection
Liquid
discarded in
drainage after
disinfection
Waste Stationery from
office
Office - Formal recycling Formal
Intact glass tubes, petri
dishes, empty glass
bottles
Lab. 5%
Hypochlorite
for 30 minutes
Autoclaved in CSSD Autoclaved in
CSSD
Recycled in
hospital
(Source: Mainstreaming Environmental Management in the Health Care Sector “Implementation
Experience in India & Tool-Kit for Managers, The World Bank)
55
V. Organizational Arrangements for Implementation
A. National Level
The responsibility for ensuring the implementation of the HCWMP lies with the MoPH,
which is the implementing agency for the SEHAT. The overall responsibilities will be
with the Secretariat (MoPH). The specific responsibility will be of the Environmental
Health Department under the General Directorate of Preventive Medicine (GDoPM) of the
MoPH. It is important to note that Environmental Health Department and its designated
Focal Officer for HCWMP implementation will work in consultation with the GCMU on
the HCWM activities and act as focal points to ensure effective, successful
implementation of this HCWM plan.
The HCWM is multi-sectoral in nature and various stakeholders such as the MoPH, NGOs
providing BPHS and EPHS in the provinces, Provincial Hospitals, PPDs, National
Hospitals, NEPA, Municipalities, Donor Agencies, Private Sector etc. would require a
close coordination for effective implementation of HCWM Plan.
Institutional Capacity Building for Effective HCWM at National Level
The Institutional Capacity for HCWM in MoPH needs to be built up considerably for the
policy and the plan to be effective. The Environmental Health Department should be made
the nodal agency and the focal point for capacity building in the HCWM area in
Afghanistan at the National, Regional, Provincial and the rural levels.
The following measures are suggested to build the institutional capacity for HCWM in
MoPH:
o A Training-cum-Orientation Trip to the existing modern Common HCWM facilities
among the neighboring countries to be arranged which will provide the Environment
health staff and the Hospital Administrators with the requisite background
information and knowledge about the planning and operational aspects of integrated
waste management facility. This orientation trip will also provide the administrators
to analyze the viability of the PPP models and the user fees structure of some
successfully operating CWTFs.
o The key staff at the Environmental Health Department and the personnel from
Health Department at Provincial level should be encouraged to undertake
specialized courses/trainings in HCWM to update their knowledge and skills.
Suggested contents for the orientation and train- the- trainers program has been
later.
o Special focus must be given on building up a team of technicians for Operation and
Maintenance functions for the HCWM equipment. The endeavor should be to
develop capacity at the Regional level as well to ensure that the procured and
installed HCWM equipment is operative with a minimal downtime.
56
o All key staff members at the MoPH including from the departments such as
Administration, Finance, Training, Procurement etc. must undergo a basic training
program in HCWM and the policy framework for the same. This will enable them to
get familiar with the HCWM concepts, policy framework, plans, procurement
schedules, training requirements, financial implications, relevance of the PPP
models etc.
o The monitoring and evaluation of the HCWM for the BPHS and EPHS service
providers at the provincial level must be entrusted to the respective NGOs. A
training program aimed at the capacity building of these NGOs on HCWM needs to
be developed and implemented.
o The above mentioned efforts need to be augmented by introducing a Train-the
Trainers program on HCWM. The major stakeholders such as the NGOs, EHD,
PPD, and Nursing Heads of major National, Regional and Provincial Hospitals
could be trained through this initiative and then they can train the relevant staff in
their respective institutions.
o A manual on formation and operation of the HCWM systems at the HCU level
needs to be prepared in Dari, Pashto and English by the MoPH in consultation with
the experts. The manual must focus on the HCWM policy, framework, Plan,
Methodology for formation and operation of a WMC at the HCU level, operational
parameters, meeting schedules, major issues, reporting systems, M&E Framework
etc. This would help to build the capacity at the HCU level to effectively implement
the HCWM policy.
The MoPH recognizes the importance of budget for Infection Control and HCWM is
allocated rather than the prevalent zero-cost approach among the health-sector
professionals, administrators and workers.
A Program for ensuring local availability of the spare parts for the HCWM Equipment as
well as the trained technicians will be implemented by the MoPH. The plant and
equipment suppliers for HCWM will be mandated to provide onsite training to the local
technicians during the installation and commissioning period and a minimum period of 6
operative months for the equipment.
B. Provincial Level:
At the provincial level, Provincial Health Directorate (PHD) and Implementing NGOs will
be responsible for the implementation of HCWMP. In the provinces, the provincial public
health directorate will assign monitoring Focal Point having proper ToR and will receive
needed training for effective implementation of the HCWMP.
57
At the district level, Provincial Health Directorate (PHD) and Implementing NGOs will be
responsible for the implementation of HCWMP. At the health facilities, this responsibility
will lie with the Head of Health Facility.
Also, each major hospital supported by SEHAT project will have a HCWM Focal Officer
with proper ToR and will report to the Hospital Director/Manager/Sartabib11
. Meanwhile,
all healthcare workers will be trained and equipped to implement satisfactory infection
control practices and sound waste management.
Institutional Capacity Building for Effective HCWM at Provincial Level
Infection Control and Waste Management systems require detailed guidance and strategic
planning to enable related activities to be implemented in a relevant and structured
manner. Most Provinces do not have plans for implementation and monitoring, with the
focus being primarily on procurement of consumables and contractual arrangements with
outsourced agencies or service providers.
The success of the PPP in providing BPHS and EPHS in the provinces by the NGOs could
be a useful stepping stone for implementing HCWM across the country with Private
Sector Participation, especially for implementing CWTFs on pilot basis as well as the 3rd
party monitoring and evaluation of the HCWM on a regular basis.
The NGOs providing BPHS at the Provincial level should have an inbuilt system for
monitoring the HCWM status in the HCUs. This should be made an integral part of the
HMIS. The NGOs should also be responsible for monitoring & reporting on any major
incidents such as Needle stick Injuries, Shutdown of the Incinerators/other HCWM
equipment etc. through exception reports.
Figure 4 is illustration of Institutional Capacity Building needs to be carried out at various
levels to ensure proper implementation of HCWM plan as well as monitoring & evaluation
of HCWM system.
11Hospital Director is known as Sartabib in Dari language
58
Figure 3 : Schematic Representation of Institutional Capacity building of various stakeholder for proper
implementation of HCWM plan
To implement the HCWM in a comprehensive systematic manner, the critical steps would be
to setup linkages between the top to bottom regulatory and HCWM plan implementing
body/agency (ies). It would also be necessary to list and clearly spell out the role and
responsibility of the different body/agency in implementation of the plan. The proposed
organization structure is illustrated at Figure 5.
Capacity building of MoPH
3rd
Party
(Monitoring &
Evaluation)
MoPH
PPU
Environment Health
Team for HCWM
Training
Provinces PPD
Provincial Nodal Officer
NGOs District
Hospitals
BHCs, PHCs &
CHCs
Focal Person for
HCWM at HCU Unit
Procurement of Equipment
and Services for HCWM
Waste
Management
Committee
General Directorate of
Preventive medicine
Environmental Health
Directorate
59
Role of Different Stakeholders
The Role of different stakeholders in health-care waste management in Afghanistan have
been worked out & presented below:
Table 13: Role of different stakeholders in health care waste management Stakeholders
Leg
isla
tion
En
forc
emen
t
Po
lici
es a
nd
Gu
idel
ines
Ca
pa
city
Bu
ild
ing
Mo
nit
ori
ng
Res
earc
h a
nd
dev
elo
pm
ent
Ex
ecu
tin
g
Ag
ency
Fin
an
cin
g
an
d
Su
sta
ina
bil
ity
La
nd
All
oca
tio
n
Co
llec
tio
n
an
d D
isp
osa
l
NEPA Yes* Yes Yes Yes Yes Yes
MoPH Yes Yes Yes Yes Yes Yes Yes
Dept. Of
Environmental
Health
Yes Yes Yes Yes Yes Yes
Municipalities Yes Yes Yes Yes
WHO Yes Yes Yes Yes Yes
Multilateral
organization
Yes Yes Yes Yes Yes
NGOs and others Yes Yes Yes Yes
Health-care
Facilities
Yes Yes Yes Yes Yes Yes Yes
Centralized
Facilities and
Yes Yes
Private
Sector/Accreditation
Bodies
Yes Yes Yes Yes Yes Yes
Yes*: This refers to the active involvement of the organization/institution in the activity
specified in the column head.
The roles of the different stakeholders in the policy legislation, enforcement, capacity
building etc. have been worked out based on the interaction with the various organizations &
key personnel as well as the prevailing Healthcare Structures in Afghanistan.
Additional Regulatory guidelines to be issued
Based on the study of regulatory frameworks and policies available in Afghanistan pertaining
to HCW, the need to introduce some of the important guidelines by the relevant authorities
for better and effective management of HCW was highlighted. For instance Sanitary
Guidelines, User fees, Compact Fluorescent Lamps, Bidding & Procurement Policy etc..
Table 14: Additional regulatory guidelines
S.N Additional Regulatory Guidelines
to be issued
Government Departments
1. SANITATION GUIDELINES NEPA, Municipalities
2. User Fees PPP Deptt, MoPH
3. CFL Lamps Ministry of Energy
4. Bidding & Procurement PPP Deptt., MoPH, Private Transaction
Advisory Service Providers
60
5. Ambient Air & Water Quality
Standards
NEPA, Afghan National Standards
Authority (ANSA)
6. Construction MoPH& Municipality
7. Infection Prevention MoPH
8. Specifications (Standards for HCW
Transport vehicles)
MoPH, NEPA, Transport Dept.
9. Mercury Spillage Control Standards MoPH, NEPA, Afghan National Standards
Authority (ANSA
10. Radioactive Wastes Disposal MoPH
11. Guidelines for CWTF MoPH, NEPA
Figure 4: Illustration of Proposed Organizational Chart.
Plan Implementation Schedule
Implementation of the HCWM Plan would include various activities including Public Consultation &
Finalization of the HCWM Plan, Exposure Visits, Training and Capacity Building, Standards for
Equipment, Procurement Policy framework, Regulatory Framework modification, Pilot Projects on
Deputy Minister for Health
Service Provision
General Directorate of
Preventive medicine
Environmental Health
Directorate
Radiation
Protection Wash Environmental
Hygiene Food
Safety Admin Training
Health Care Waste
Management
(Staffed with 7 Technical
Regional HCWM Officer
Provincial HCWM Officer
HCWM Focal Point at
each Hospital
HCWM Focal Point at
each BPHS Health
Faculties
61
CWTF, Implementation of HCWM Plan at the HCU level, NGOs training, Integration with the HMIS,
M&E Framework implementation etc. The complete framework for the complete implementation of the
HCWM plan is expected to be about 2 years.
The overall implementation plan for HCWM in Afghanistan is illustrated at Figure 5. The proposed
Implementation Schedule for HCWM Plan has been detailed at Figure 6. The said plan is expected to be
implemented over a period of 24 months approximately.
62
Figure 5: HCWM Implementation Plan
Public
Consultation
Finalisation of Policy
and HCWM Plan
Orientation
Program/Train- the
Trainers
Exposure Visit of a few
Major Stakeholders Training of NGOs,
PPDs, Other
Stakeholders
Detailed HCWM Plan
Regulation
Framework
Draft Policy
& Plan
Legislation, NEPA
Planning for Pilot
Project
Other Legislations, Bye-Laws &
Framework ( Water, Air, CWTF,
landfills Construction etc)
Procurement Policy ( Laying down
of relevant specifications)
Setting of equipment standards
Training & Capacity Building,
Manpower Resource
M&E Framework Implementation
PPP Framework
Tendering for Pilot
Project Implementation of Pilot
Project
Monitoring & Evaluation
By NGOs
By Independent
Agency
Review of HCWM
Plan and Course
correction if required
HCWM Implementation
Procurement
WMCs
Training
Linkages with CWTF (if
applicable) HCWM Plan for National,
Regional, Provincial Hospital
HCWM Plan for HCUs located in
Rural/far-flung areas
63
Table 15: Proposed implementation schedule for HCWM Plan
Activities 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Finalization of the Plan Document
Acceptance by Stakeholders
Exposure Visit
Orientation/Training the Trainers’
Program
Standards for Bins, Equipment, PPEE
Vehicles, Burial Pits, Trolleys etc.
Procurement
Regulatory Framework
Pilot Project Planning & Implementation
including CWTFs, Landfill Sites, Storage,
Secondary Storage, PPE etc.
Implementation of HCWM Plan
Guidelines for Regional Hospitals &
Provincial Health Care Centre
NGO Training
HMIS
Pilot Project Roll Out
M&E Framework Implementation
including 3rd
party monitoring
The CWTFs proposed to be implemented as part of the HCWM should be implemented based on a PPP model with the Private operator managing the HCW treatment & disposal at the landfill site apart from secondary collection & transportation of the HCWM from the HCUs. The revenue model could be based on a fixed cost to the HCU on a per bed norm on daily basis. The PPP department of the MoPH should be made an important stakeholder in developing this model.
Month
64
VI. Operational Framework
A. Introduction
This chapter includes an overview of operational guiding principles on the components related to
HCWMP. The purpose of this compilation is to have a single, first-level and easy-to-use
reference. These guidelines draw from a number of publications / websites of WHO and other
organizations.
The standardization of the current HCWM practices with the application of rigorous on-going
management and monitoring procedures, based on the Laws and National Guidelines.
Action Points for development of a comprehensive Healthcare Waste Management Plan include
the following:
A few key action points have been identified for implementing HCWM Plan
1) Formation of Waste Management Committee (WMC)comprising of Heads of the Hospital,
Nursing Superintendent, Doctor/Nurse from Infection Control Committee, Sanitary
Supervisor, Store-in Charge and supervisor of Housekeeping Staff
2) The designation of a Health-Care Waste Management Officer (HCWMO) who should be
given the responsibility to operate and monitor the management of the HCW on a daily
basis;
3) Standardized segregation procedures should be set-up in all
Afghan HCFs by implementing a three bins system that
should be systematically associated with a color coding, a
labeling system as well as minimizing procedures;
4) The development of specific treatment/disposal methods according to the type and the
location of the HCFs where the waste is generated.
5) Proper collection points/stores are needed to avoid the current stage dumping of the
medical wastes in the hospital compound where it is contaminating the air and the hospital
environment. (Table 3 above)
6) Feedback form from HCUs on Quantification & characterization of HCW as well as
existing status
7) Training Kit & Manual (Dari & English versions). A manual may be developed which
should be made available to the public and the end-user as a reference book for the
following:
Setting up of Waste management Committee, Factors to be considered for the selection of Technology
Color codes to be practiced
layout specifications for construction of Burial Pits
Safety guidelines to be followed
Manual for Symbols and Labels to be used, routes layout out etc.
Sharp Management Plan
The development of manual is already underway.
8) Orientation Program for all Major stakeholders
9) Setting Standards and specifications for Equipment
10) Regional, Provincial & HCU level plans
11) Exposure visit of Major stakeholders i.e. Environmental Health, PPP Divin. Major MoPH
Stakeholders i.e. Hospital Administrators
12) Pilot Project with Kabul Municipality
13) Train the Trainers program
14) NGOs training on HCWM and Monitoring & Evaluation
15) Bidding of Pilot Project with active involvement of PPP Division, MoPH
16) Procurement of Equipment
17) Plans for Building Ambient Air specs, Burial Pits, Drinking Water Quality, Chimney
Height for Incinerators with assistance from NEPA
18) Identification of Nodal persons/Focal Points at Provincial & HCU level
19) Formation of waste Management committee
65
20) Specific Plans for HCUs location Remote Area/Rural Areas
21) Report on Feasibility of CWTFs & action plan
22) AMCs for the existing Incinerators and other HCWM equipment
23) Recruitment of an Independent Agency for 3rd party M&E of HCWM in each of the
Provinces
24) System for Approving/Registering Special Vehicles for carrying BMW.
25) Reporting Formats for HCWM at HCU level, Provincial level & the National Level
26) Roll-out Plan at the National, Regional & Provincial levels
27) Evaluate the impact of the HCWM Preparatory & Initial phase to develop the strategy for
the subsequent years
28) Training of the technicians handling HCWM equipment such as Incinerators, Autoclaves,
Microwaves and shredders
29) Training of the Focal Persons at the Provincial level responsible for planning &
implementing HCWM in the respective provinces.
The role and responsibility of Waste Management Committee, their functions etc. have been
illustrated at Annexure V.
B. Hospitals and health facility
HSCs/BHCs/CHCs
The operational framework and overall plan for healthcare waste at this level depends upon what
services are being offered and identification of types of waste and quantity of waste to be
generated from these facilities.
As per the revised BPHS Package, 2010/1389 the BHC is a facility offering primary outpatient
care, immunizations and Maternal and Newborn care. Services offered include antenatal,
delivery, and postpartum care; newborn Care ,nonpermanent contraceptive methods; routine
immunizations; integrated management of childhood illnesses; treatment of malaria and
tuberculosis, including DOTS; and identification, referral, and follow-up care for mental health
patients and persons with disabilities including awareness-raising.
The services of the BHC cover a population of about 15,000–30,000, depending on the local
geographic conditions and the population density. In circumstances where the population is very
isolated, the catchment population for a BHC can be less than 15,000. The minimal staffing
requirements for a BHC are a nurse, a community midwife, and two vaccinators. Depending upon
the scope of services provided and the workload of the BHC, up to two additional health care
workers may need to be added to perform well-defined tasks (e.g., supervision of community
health workers and
The CHC covers a catchment area of about 30,000–60,000 people and offers a wider range of
services than does the BHC. In addition to assisting normal deliveries, the CHC can handle
certain complications, grave cases of childhood illness, treatment of complicated cases of malaria,
and outpatient care for mental health patients. Persons with disabilities and persons requiring
physiotherapy services will be screened, given advice and referred to appropriate services in the
area. The facility usually has limited space for inpatient care, but has a laboratory. The staff of a
CHC is larger than that of a BHC; it includes both male and female doctors, male and female
nurses, midwives, one (male or female) psychosocial counsellor when mental health activities are
implemented, and laboratory and pharmacy technicians. Physiotherapists will visit CHCs on an
outreach basis from the district hospital.
Typical health care wastes to be generated from above health facilities include Sharps,
Pathological waste and potential infectious wastes. These can be further elaborated as Needles,
Scissors, Razors, Broken glass, Body tissue, Fetuses, Body fluids, etc. Dressings, PVC tubing,
Culture dishes, Test tubes, Vials, etc.
66
The incinerator as a treatment and disposal technology is not viable as in absence of requisite
quantity of waste these become inoperative. The ideal approach would be that these wastes from
point of production would be segregated according to the color codes and anatomical wastes
would be buried inside the burial pit and sharps into sharp pit after shredding and autoclaving of
the same. The other general wastes (food etc.) needs to be linked with the MSW wastes. Wastes
such as plastic bags, piston, syringe barrel etc. may be sent for recycling after getting them
disinfected. Refer the Figure 6: illustrating the steps involved in this approach. Option II in
given in the figure can be adopted where CWTF is viable or located in nearby areas.
Figure 7 Schematic Diagram of HCWM Plan to be adopted at HSCs/BHCs/CHCs level
The guideline for construction of pits is provided at Annexure VI. This method is not new for
Afghanistan; this is already being practiced at some of the healthcare facility already doing this.
This method is also compliant with the Infection Prevention Control Act and Policy of the
country which clearly underlines and prohibits the burning of infectious wastes. A table,
containing evaluation of different technologies and factors to be considered while opting the
technology for health care waste management, is provided at Annexure VII.
C. Storage Facility
All health-care facilities would be required to have a clearly designated waste storage area. The
Waste storage area has to be well-ventilated, with adequate space to store infectious and non-
infectious waste, and secured from pilferage. The shortage of storage areas results in the mixture
of waste or creation of overflow which allows animals and scavengers easy access to infection
waste. Another area of concern is the storage of insecticide stocks for vector control activities at
primary healthcare facilities. This tends to be poor, with insecticides often being stored close to
pharmaceutical stocks or in village houses where spraying operations take place. The
responsibility to supervise the internal collection of wastes, their transportation, availability of
waste bags, protective clothing and collection carts and crews should be given to a designated
officer. i.e. In charge of HCWMO at the HCF.
The storage areas within the premises of the HCFs where no in-situ treatment & disposal is
recommended and are linked with the CWTF, a uniform color-coding for different types of HCW
needs to be followed as with the Bins, Bags & Trolleys to ensure uniformity & avoid confusion.
Shredder Autoclaving/
Microwave
Segregation of Waste
according to the color
codes
Sharp Pit
Burial Pit MSW Waste Carrier
Sharps
Anatomical
Wastes, Infectious
wastes
General Wastes
Health Facility
Option I
Option II
Common Waste
Treatment Facility Centre
67
D. Infection Control
It is very important to note and recognize that infection control is the responsibility of all
healthcare professionals – doctors, nurses, pharmacists and others. Preventing nosocomial
infections requires a hygienic and sanitized environment and maintenance of good practices and
use of protective gear. Routine cleaning of the health facility is absolutely essential, as that will
keep the environment free from dust and soil.
Running water, soaps or antiseptic and facilities for drying without contamination, are required
for healthcare workers to maintain cleanliness at all times. As a general practice of maintaining
good hygiene, the floors of the healthcare facility should be first swabbed with a wet cloth, then
swept to remove grits to avoid dust carrying pathogens from rising into the air and, finally,
swabbed with a disinfectant solution. The swab cloth should be washed with detergent after every
use. Infected linen in the hospital should be carefully packed in plastic bags, taken to the washing
area, stored in bleach solution and then washed with the usual cleaning agents.
Spill Control
Spillage usually requires clean up only of the contaminated area. For spillage of infectious
material, however, it is important to determine the type of infectious agent; in some cases,
evacuation of the area may be necessary. Procedures for dealing with spillage should specify safe
handling operation and appropriate protective clothing. In case of skin and eye contact with
hazardous substance, there should be immediate decontamination. The exposed person should be
removed from the area of the incident for decontamination, generally with copious amounts of
water. Special attention should be paid to the eyes and any open wounds. In case of eye contact
with corrosive chemicals, the eyes should be irrigated continuously with clean water for 10-30
minutes; the entire face should be washed in a basin, with the eyes being continuously opened
and closed.
General Guidance for Spill control
a) Vacate and secure the area to prevent further exposure of other individuals.
b) Provide first aid and medical care to injured individual.
c) Inform the designated person (usually the waste management officer) who should
coordinate the necessary actions.
d) Determine the nature of the spill.
e) Provide adequate protective clothing to personnel involved in cleaning –up
f) Limit the spread of spill.
g) Vacate all people not involved in cleaning up of the spillage involves particularly
hazardous substance.
h) Neautralize or disinfect the spilled or contaminated material if indicated.
i) Collect all spilled and contaminated material (sharps should never be picked up by
hand; brushes and pans or other suitable tools should be used). Spilled material and
disposable contaminated items for cleaning should be placed in the appropriate waste
bags or containers.
j) Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or
other absorbent material) should be turned during the process, because this will spread
the contamination. Working from the least to the most contaminated part, with a
change of cloth at each stage should carry out the decontamination. Dry cloth should be
used in the case of liquid spillage; spillage of solids, cloth impregnated with water
(acidic, basic, or neutral as appropriate) should be used.
k) Decontaminate or disinfect any tools that were used.
l) Seek medical attention if exposure to hazardous material has occurred during the
operation.
E. Treatment and Disposal of Health Care Wastes
All HCFs should treat and dispose the medical waste as per Table 11.
All sharps in their puncture proof containers should be disposed in the sharps pit, which is
to be located within the premises of the HCF.
68
Infected organic waste, after disinfection, should be taken to the onsite deep burial pits and
covered with a layer of lime and soil.
Infected recyclables such as plastics and metals should be first disinfected using bleach
solution and / or autoclaved before sent for recycling.
Collection of garbage / municipal solid waste, the general / communal waste – non-
infected - should be managed with Common municipal waste treatment facilities. Organic
waste such as kitchen waste and leaf fallings would be collected and transported with
common municipal solid waste and depart for windrow composting at the landfill site.
Recyclable material such as packaging material and paper should be sold to authorized
recyclers or to link with Municipal Wastes. Care must be taken to ensure that the
recyclable waste is not infected and kept separated from infectious wastes at all times.
All equipment used for bio-medical waste treatment should be periodically maintained. Both
preventive and corrective maintenance schedules and records should be retained in the HCF.
Activities undertaken to improve health services, especially in major health centers and hospitals
will inevitably create waste that is potentially hazardous. Health care wastes are typically more
hazardous that other types of wastes and are of concern in assessing proposed health care
improvement activities. To address these concerns, it is essential to put in place safe and reliable
methods for handling and proper disposal of HCW.
Health care waste includes all wastes generated in the delivery of health care services. WHO
(1999a) estimates that 75-90% of waste produced by HCF originates from non-risk or general
sources (e.g., janitorial, kitchens, administration) and is comparable to domestic waste. The
remaining 10-25% of HCWM is classified as hazardous and poses a variety of potential health
risks.
Table 16: General Waste Management Rules
Option Waste Category Treatment and
disposal
Current practices
1 Human anatomical waste ( human tissues, organs,
body parts)
Incineration/ deep
burial
Incineration/ deep
burial
2
Animal waste (animal tissues, organs, body parts
carcasses, bleeding parts, fluid, blood and
experimental animals used in research, waste
generated by veterinary hospitals colleges,
discharge from hospitals, animal houses)
Incineration/ deep
burial
Incineration/ deep
burial
3
Microbiology & Biotechnology waste (wastes
from laboratory cultures, stocks or specimens of
micro-organism live or attenuated vaccines,
human and animal cell culture used in research
and infectious agents from research and industrial
laboratories, wastes from production of biological,
toxins, dishes and devices used for transfer of
cultures)
Local autoclaving/
microwaving/
incineration
Local autoclaving/
incineration
4
Waste sharps (needles, syringes, scalpels, blades,
glass, etc. that may cause puncture and cuts. This
includes both used and unused sharps)
Disinfection (chemical
treatment/ autoclaving/
microwaving and
mutilation/ shredding)
Disinfection
(chemical
treatment/
autoclaving)
5
Discarded medicines and cytotoxic drugs (wastes
comprising of outdated, contaminated and
discarded medicines)
Incineration,
destruction and drugs
disposal in secured
landfills.
Incineration,
destruction and
drugs disposal in
secured landfills.
6
Solid waste (items contaminated with blood, and
body fluids including cotton, dressings, soiled
plaster casts, lines beddings, other material
contaminated with blood)
Incineration /
autoclaving/
microwaving
Incineration /
autoclaving
69
7
Solid waste (wastes generated from disposable
items other than the waste sharps such as tubing,
catheters, intravenous sets. Etc)
Disinfection by
chemical treatment/
autoclaving/
microwaving and
mutilation shredding
Disinfection by
chemical
treatment/
autoclaving
8
Liquid waste (waste generated from laboratory
and washing, cleaning, house-keeping and
disinfecting activities)
Disinfection by
chemical treatment and
discharges into drains
Disinfection by
chemical treatment
and discharges into
drains
9 Incineration Ash (ash from incineration of any
bio-medical waste)
Disposal in municipal
landfill
deep burial in the
health facility
10
Chemical waste ( chemicals used in production of
biological, chemicals used in disinfection, as
insecticides, etc)
Chemical treatment and
discharge into drains
for liquids and secured
landfill for solids
NA
F. Segregation of Waste and Onsite Storage
Segregation of waste at source is a single most important step in bio-medical waste management. Once
bio-medical waste mixes with general waste, the waste management problem magnifies and becomes
unmanageable. It is critical that wastes be segregated at the point of generation itself. The following
Table-17 gives the segregation method that should be used for the various categories of waste. All waste
containers should be made of good quality plastics or other strong material. These should have smooth
inner and outer surfaces to avoid dirt / dust sticking in indentations. They should be lined with non-
chlorinated plastic liners and should be kept closed at all times. The onsite storage locations should be
properly planned and be made available. Ideally, these should be nearest to the point of generation. Where
potentially infected wastes are generated, 2% bleach solution (freshly prepared twice a day) should be put
in the waste container and the waste should be put in the container having this solution. The quantity of
waste in each of the waste containers should be weighed and a log should be maintained. This should be
done prior to evacuating the container into the final onsite disposal.
Table 17: SHC, BHCs, and CHCs’ Wastes
Type of Waste
generated
Waste management
method
Staff training Remarks
Sharps:
Needles
Scissors
Razors
Broken glass,
etc.
Segregation into
puncture-resistant
containers. Deep
burial.
Use training provided to
vaccinators as the basis for
staff handling this type of
waste.
Segregation into puncture-
resistant containers. Deep
burial.
Pathological waste:
Body tissue
Fetuses
Body fluids, etc.
Deep burial. Teach staff to dispose of
these materials immediately.
Will need designs for deep
burial pit covers that allow
these wastes to be easily
dumped
Potentially infectious waste, containers with blood products :
Dressings
PVC tubing
Culture dishes
Test tubes
Vials, etc.
Deposit into color-
coded bag.
Deep burial.
Make staff more aware of
the dangers of this kind of
waste and how to store these
materials
Little experience with
segregating and proper
disposal of these materials.
The waste from containers should be transported to the appropriate disposal points. All personnel
responsible for the waste containers should wear gloves, masks, aprons and proper footwear. The
personnel should wash their hands and feet with soap and disinfectant solution after every handling of
these containers. Cleaning (sweeping and swabbing) should be undertaken twice daily and all the waste
from the dust bins should be emptied twice a day. No infectious wastes should be stored beyond 24 hours.
70
G. Transportation of health care Waste
Medical wastes have to be transported both within the health facility and from the facility to the final
disposal location. Properly designed carts, trolleys and other wheeled containers will be used for the
transportation of waste inside the facilities. Wheeled containers shall be so designed that they have no
sharp edges. Waste handlers must be provided with uniform, apron, boots, gloves, and masks, and these
should be worn when transporting the waste as described earlier.
H. Use and Disposal of Auto-Disable (AD) Syringes
The MoPH recommends that Auto-Disable (AD) syringes are to be used for immunization instead of
glass or disposable syringes. In parallel to introducing AD syringes, MoPH has also developed and
disseminated detailed user guidelines that outline steps that should be followed when using an AD syringe
and disposing of AD syringes. Table 1818 defines the steps to be followed for use and disposal of AD
syringes.
Table 18: Instruction for use of AD syringes
No. Steps/ Stages
1 Select the correct syringe for the vaccine to be administered
2 Check the packaging. Don’t use if the package is damaged, opened or expired.
3 Peel open or tear the package from the plunger side and remove the syringe by holding the plunger.
Discard the packaging into a black plastic bag.
4 Remove the needle cover/ cap and discard it into the black plastic bag. Do not move the plunger
until you are ready to fill the syringe with the vaccine and do not inject air into the vial as this will
lock the syringe
5 Take the appropriate vaccine vial, invert the vial, and insert the needle into the vial through the
rubber cap. Insert the needle such that the tip is within the level of the vaccine. If inserted behind
you may draw air bubble, which is very difficult to expel. Do not touch the needle or the rubber
cap) of the vial.
6 Pull the plunger back slowly to fill the syringe. The plunger will automatically stop when the
necessary dose of the vaccine has been drawn (0.1 or 0.5 ml) .do not draw air into the syringe. In
case air should accidentally enter the syringe. Follow these steps to remove the air bubbles:
(a) Remove the needle from the vial. Holding the syringe upright, tap the barrel to bring the bubbles
towards the tip of the syringe.
(b) Pull the plunger back to allow air to come in through the needle until it comes in contact with
the air bubble in the syringe barrel.
(c) Then carefully push the plunger to the dose mark ( 0,5 or 0.1 ml) thus expelling the air bubble
7 Clean appropriate injection site, if necessary with a wet swab and administer the vaccine
8 Push the plunger completely to deliver the dose till it gets locked.
9 Cut the hub of the syringe immediately after use with a hub-cutter that collects the sharps in a hard
white translucent plastic container. Do not recap the needle. Then collect the cut syringes in a red
plastic bag. The cut/destroyed syringes, barrels and needles must be disinfected at the designated
place and properly disposed off.
I. Reporting System
The practice of record keeping shall be a step towards achieving the goal of institutionalizing the
HCWM system internally wherein all necessary information shall be trapped at ward/unit level in the
hospital. This shall be subsequently consolidated by the waste management in-charge to prepare the
monthly report to be sent from the HCU at the provincial level. This practice of record keeping shall
also enable the hospital authority to meet up the legal requirements as per the new policy. The
tracing of different waste management activities shall also be possible if a proper system of record
keeping remains in vogue.
The record to be kept shall be of distinctly two types- one for keeping all records related to HW to be
generated within the HCU and the other to track performance of the scavenging contractor engaged
for the non-clinical (Sanitary and scavenging) services in the hospitals (wherever applicable).
Specific formats of registers have been developed for keeping both types of records which has been
discussed below:
a. Record Keeping by Hospital Staff
71
Some records shall be maintained in specified registers to capture various information pertaining
to the HCWM at various locations within the hospital by the hospital staff. The salient features
about these registers and the responsibilities are given below:
i) Labelling of Bags
During collection of the bags from the bins, the bags shall be tied up at the neck and
labeled indicating the date of collection and name of ward/unit. The responsibility of this
lies with the attending nursing staff for each ward and assigned hospital staff for other
units. The labels shall be signed by the concerned staff.
ii) Waste Collection Records
In order to institutionalize the HCWM system at the ward and unit level, a waste
segregation register shall be maintained by the ward nurse or concerned hospital staff to
record the number of bags being generated from the units. Attending ward sister or staff (
for other units) shall enter the number of different colored bag in duplicate (carbon copy)
in the specified format, sign and send it to the In-charge, WMC. The In-charge shall
receive, countersign and keep the original for further entry and send back the duplicate
copy to the ward/unit for their records.
b. Waste Management Record
A register shall be maintained by the In-charge, WMC of the hospital to collect daily record of
aggregate number of colored bags collected from the wards and units. The WMC after receiving
the copies of the waste segregation registers from al the units shall consolidate the records to
calculate the total number of bags generated on that day.
This record shall be maintained on a daily basis and finally be consolidating at the end of the
month to prepare the monthly waste management report.
c. Waste Treatment Records
The operator of the waste autoclave shall maintain records of the usage of the autoclave
and submit the records to the WMC for consolidation. A register shall be maintained by
the operator in which the following records shall be maintained. Daily record of boiler
operation, treatment cycle details, usage of autoclavable bags, and number of bags
containing infectious plastic waste.
J. Common Waste Treatment Facilities Centre (CWTFs)
A common healthcare waste treatment facility is a set up where healthcare waste, generated from
a number of healthcare units, is imparted necessary treatment to reduce adverse effects that this
waste may pose. The treated waste finally is sent for disposal in a landfill for recycling purposes.
This as an option has already been legally introduced and successfully being operated in other
country like India.
The coverage Area for One CWTF may be allowed to cater up to 4000 beds at the approved rate
by the prescribed authority such as NEPA. However in an area where 4000 beds are not available
within a radius of 100 km, another CWTF may be allowed to cater the healthcare units situated
outside the said 100 km.
Pilot CWTF Projects in 6 major Towns i.e. Kabul, Mazar, Jalali, Heart, Kandhar, Ghazni) should
be taken up preferably on a PPP basis and the outcome and the impact of the same post –
implementation should be ascertained and corrective action if required should be taken for the
subsequent projects.
The guidelines and standards to be followed up while setting up CWTFs have been provided at
Annexure VIII.
72
Awareness and Training
b. Awareness
Every province should plan and undertake general awareness raising activities for IMEP,
which should include all levels of healthcare facilities. All IMEP related awareness activities
should be fully integrated with those being undertaken under the other national health
programs.
Professional bodies like health promotion department of MoPH can be involved in enhancing
understanding and promoting good practices. At the health facilities, appropriately located
display of IEC materials is most effective in ensuring that workers follow segregation,
treatment and infection control practices.
Public Consultation is an important ingredient of any HCWM Plan. It is proposed to have
extensive public consultations at various levels with different stakeholders in Afghanistan
such as NGOs, Hospital, Administrators, Municipalities, Doctors and other medical staff,
elected representatives, community, relevant government ministries and departments. before
the proposed HCWM plan is taken up for implementation. It is also suggested that since the
“ownership” by the various stakeholders is an important criteria for its success, the HCWM
plan may be subjected to minor changes & modifications based on the feedback received
during the Public consultations while meeting the overall Environmental compliance criteria
and the world Bank Safeguards.
The capacity of the stakeholders to adopt the HCWM Plan would also be ascertained during
the Public Consultations and the training programs would be worked out accordingly. The
Public Consultation process would also help to create awareness among the stakeholders
including the Public at large which could be further augmented during the HCWM
implementation through the IEC material.
The proposed HCWM plan apart from being disseminated through the websites of MoPH and
The World Bank, must also be shared with all the participating NGOs and the concerned
PPDs, Municipalities, HCUs, NEPA etc. so that a direct feedback from various stakeholders
could be received. Based on the feedback and the comments, the final HCWM Plan within
the broad framework of the HCWM policy could be finalized before the Policy is taken up
for framing the regulations.
The other relevant guidelines, policy changes etc. required for implementing the HCWM plan
also be ascertained during the Public Consultation process.
c. Training
i) Capacity Building at Central and Provincial Levels
The reinforcement of the institutional capacity will be done at National and provincial
levels through specific technical training to support the HFs in implementing the new
HCWM policy.
The exposure to the new concepts such as CWTFs, Color- Coding, Sanitary Land
filling, Deep Burial Pits, New equipment as Double Chamber, Incinerator,
Autoclaves, and Shredders etc. need to be provided to the various stakeholders.
The PPHD will be responsible for training of its staff in HCWM plan implementation.
There are two modules for training modules – (i) train-the-trainer and (ii) regular on-
going training within the health facilities. The implementing NGOs will undertake a
needs identification to facilitate planning and allocation of budget for this activity. It is
envisaged that all health facilities under intervention areas of the SEHAT project have
officially recognized trained health personnel who will be responsible for health care
waste management. Existing awareness and training materials can be used to further
develop the skills for the sound management of health care wastes. These resources will
be available at MoPH and NGOs.
73
a. Training of The Trainers (TOT) Program
An outline of train the trainers program should be in line with the following
table (Table 19).
Table 19: Training of the Trainers (TOT) Program
DAY 1
Inaugural SEHAT, BPHS, EPHS
Session 1 Introduction to HCW & HCWM
HCWM POLICY & PLAN
Organizational structures
Session 2 Infection Prevention
Policy
PPE
Lunch
Session 3 Waste Collection & Segregation
Color-Coding of Bins
Sharps Management
Location of Bins
Session 4 Waste Transportation & Secondary
Storage
Color-Coding of Boxes, PP Containers, Trolleys, VATs
etc.
DAY 2
Opening Remarks
Session 1 Waste Treatment
Disinfection
Autoclaving /Hydroclaving
Session 2 Waste Disposal
Ash from Incinerators
Disinfected Sharps waste
Disinfected other Infection Waste
General Waste
Session 3 Technologies and Equipment
Lunch
Session 4 Training
Waste Management Committee
Implementation Schedule
Reporting systems
Monitoring & Evaluation
Session 5 PPP
CWTF
Valedictory Session Feedback
Action Plan
Vote of Thanks
b. Regular On-Going Training Within The Health Facilities
Training of Healthcare Personnel
The training needs to be imparted to all health-care professionals on waste
management issues, not only to provide them with the core knowledge, skills and
attitude to effectively work for the implementation of proper waste management
but also to make them understand the importance of good waste management
practices within and outside the health-care facility. The role of different health-
care providers and common messages on proper waste management practices
should be communicated to health care workers.
Target Groups: o Health Care Facility managers and Administrative Staff responsible for
implementing regulations on health care waste management
o Medical Doctors
o Nurses and Assistant Nurses
o Cleaners, Porters, Housekeeping Staff and Waste handlers
74
Contents of the Training Program for Healthcare Personnel
The training programs should contain broadly the following topics
o Hazards of Health-care Waste
o Infection Control Measures
o Healthcare Waste Management and Handling Policy in the country
o Waste Management Steps; Waste Collection, Segregation, Transportation,
Storage, Treatment and Disposal
o Liquid Waste Management
o Cleaning of Spills
o Principle of Waste Minimization
o Alternatives to hazardous chemicals
o Occupational Safety Issues
The information about the basic Health Care Waste Management system need also
be included in the program.
Training Package for each Target Group
The development of a training package should be suitable for the various types of
healthcare establishments including CHCs, PHCs etc. A classification of training
package can be made as under:
For Personnel providing Health Care
For Waste Handlers: Topics covered may include the best practices for waste
management, health hazards, on site transportation, storage, safety practices and
emergency response.
For Health Care Waste Management Operators: Training course should include:
i) Information on the risks associate with the handling of health care waste;
ii) Procedures for dealing with spillage and other accidents
iii) Correct use of Protective clothing
For Staff who transport the Waste: The purpose of training to these group is to enable
the staff to carry out all procedures for:
i) Handling, Loading and unloading of waste bags and containers
ii) Dealing with Spillage or accidents
iii) The use of Personal Protective Equipment (PPE) and ;
iv) Documentation and recording of health care waste, e.g. by means of consignment
note system to allow waste to be traced from the point of collection to the final
place of disposal.
For Treatment Plant Operators (TPOs): Arrangement of Training for the prospective
TPO should be made by healthcare establishments. The contents should be in line with
the following:
General operation of the treatment facility
Health, Safety, and environmental implications of treatment operations;
Technical procedures for plant operation
Emergency response, in case of equipment failures and alarms for example;
Maintenance of the plant and record keeping;
Surveillance of the quality of emissions and discharges, according to the
specifications
Training of health facility staff on HCWM is budgeted under component 1 of SEHAT for
health workers. The NGO (18 provinces) will have provisions in their contracts to
training the health facilities focal HCWM focal points. The MoPH-SM will train the
75
Environment Health
Officers of province
District -1 Province/Regional
Hospital NGO District -2 NGO
Directorate of Env.
Health
BPHS & EPHS
Providers MOPH
heath facility HCWM focal points in 4 provinces. The resources for the training of
management level for the MoPH personal in the HCWM department as well as at the
provincial level will come from the second component of SEHAT. During first life of this
HCWMP (first 6 months) the training materials will be developed, the trainers will be
identified. Once the comprehensive HCWMP is developed after the first 6 months, the
actual trainings will start in a cascade manner. The trainers will be trained in Kabul both
among MoPH and NGO staff. Then these trainers will conduct training for the provincial
level HCMM focal points, who will in their turn train the HCWM focal points at health
facility level.
The Ministry of Public Health with the help of World Bank will have a South to South
Exchange visits and cooperation with the Health Ministry of India on the Health Care
Waste Management system creation in the Afghanistan. This program, SAR Health
Care Waste Management Knowledge Exchange (SSKE Visit), is funded by a trust
fund and will help the MoPH in Afghanistan to improve HCWM practices in the country.
VII. Monitoring
a. Internal
As a part of SEHAT, quarterly progress monitoring would be done at all levels, i.e. provincial
and health facilities. In turn, MoPH will have to submit quarterly progress monitoring reports
to the multilateral departments. These quarterly progress reports should include a collation /
aggregation of the data / information compiled in each health facility.
The review will cover the following:
Status of HCWMP implementation, positive outcomes and how to improve poor
performance
Training implementation and its effectiveness
Need for modifications to existing operational guidelines or introduction of new
guidelines
A set of monitoring indicators for implementation HCWM plan should be merged with
the existing M&E system
Currently Environment Health Officers of Province monitor and evaluate the waste
management practice at the Provincial level and at District level and at Local Level NGOs
play crucial rule in waste management in Afghanistan. Figure 9 is illustration of Existing
HCWM monitoring and Evaluation (M&E) framework in Afghanistan.
Figure 4: Existing HCWM- M&E Framework
Monitoring and evaluation of BPHS
76
In order to effectively monitor and evaluate BPHS, the ministry focuses on results defined by
the Health and Nutrition Sector Strategy (HNSS) and Millennium Development Goals.
National targets have been defined in the HNSS to be achieved by 2013. However, specific
targets should be set at the provincial level based on the results of provincial household
surveys.
Information and reports produced by the MoPH, other ministries, and agencies that are used to
gather information on performance and implementation of BPHS include:
1. Health Management Information System (HMIS) providing information in facility-based
estimates for select process indicators;
2. National Health Services Performance Assessment providing information on process and
outcome indicators;
3. Census figures provided by the Central Statistics Office provide population estimates at
village, district, province and national levels;
4. Household surveys such as the Afghanistan Health Survey (AHS), Multiple Indicator
Cluster Surveys (MICS) and National Risk and Vulnerability Assessment (NRVA)
providing information on selected primary health and nutrition indicators at population
level;
5. Other special studies, like qualitative surveys, measurement of maternal mortality, etc.
b. External
Given the need to avoid self-evaluation by NGO, hospital managers, and MoPH program
managers, that could result in conflicts of interest, independent, third party evaluation will be
extensively used. This will allow the MoPH to hold NGO and hospital managers accountable
for tangible results. It will also allow all stakeholders to have an independent assessment of
progress in health service delivery.
The NGOs providing BPHS at the Provincial level should have an inbuilt system for
monitoring the HCWM status in the HCUs. This should be made an integral part of the HMIS.
The NGOs should also be responsible for monitoring & reporting on any major incidents such
as Needle stick Injuries, Shutdown of the Incinerators/other HCWM equipment etc. through
exception reports.
Monitoring will be undertaken by trained staff through 3rd
party monitoring of facilities under
the PPAs. Feedback on the performance of the waste management system will be provided at
facility, provincial, and national levels. The results of this monitoring will be used in the
formulation of the Action Plan for Management of Health Care Waste.
The project will support annual surveys of facilities delivering the BPHS to assess quality of
care, availability of inputs, staffing, supervision and waste management. This effort will build
on the successful experience with the “balanced scorecard” assessments that have provided
annual data on more than 630 health facilities nation-wide and form a rich source of
information on quality of care, availability of key inputs, and human resources.
The project will support annual hospital assessments in all public hospitals in the country.
MoPH has made great strides in having a well-functioning HMIS that provides near real time
data coming from the administrative recording and reporting system. Quarterly reports from
the national HMIS will be used by the project to assess progress and identify critical issues.
Table 20: List of Indicator for monitoring of HCWM
Indicator Baseline Target Data source
Proportion of health facility in
which safety boxes or closed
containers are being used properly
for disposal of used sharps
84.4 10 Point
increase
over
baseline
Third party
HFA
Proportion of health facility in 68.6 10 Point Third party
77
which syringes are being disposed
of WITHOUT being recapped
increase
over
baseline
HFA
Proportion of health facility with
posted procedures for
decontamination procedure steps
61.7 10 Point
increase
over
baseline
Third party
HFA
Proportion of health facility with a
basin with a water source and soap
available in this room
65.6 15 Point
increase
over
baseline
Third party
HFA
Proportion of health facility in
which disinfectants are being used
64.2 16 Point
increase
over
baseline
Third party
HFA
Proportion of health facility in
which evidence that the incinerator
is being used regularly
68 12 Point
increase
over
baseline
Third party
HFA
Proportion of health facility that
disposable syringes are being used
for all injections
99.8 Maintain
the baseline
Third party
HFA
Proportion of health facility with
evidence that the sterilizer is being
used regularly
66.5 15 Point
increase
over
baseline
Third party
HFA
Key components of the HCWM need to be monitored
The Key components of the HCWM need to be monitored at regular intervals to ensure that the
HCWM Plan is being implemented effectively. The factors which need to be constantly
monitored at the HCU level are as follows:
o Formation of Waste Management Committee (WMC)
o Notification of the Focal Person for HCWM.
o Number of Training Programs organized on HCWM and the number of trainees
o Procurement & Consumables including PPE, Bins, Bags, Autoclaves, PP Containers
Trolleys etc.
o Enclosed Secondary Storage space for HCW within the premises
o Effective implementation of the color-coding for HCWM.
o Reporting systems for HCWM and Exception Reports
o Proper Sharps Management
o If located in Rural/Remote Area, provision for Deep Burial Bits as per the
specifications
o Immunization for Waste collectors.
o Compliance with the IP Protocol
o Segregation of General Waste from Biomedical Waste
o Segregation of different types of BMW e.g. Anatomical Waste, other Infections
waste and sharps waste.
o Proper primary collection and transportation of segregated BMW in closed Bags to
Secondary storage.
o Linkages with the CWTFs if treatment not being done insitu.
o If Incinerator is installed in the premises its location should be proper, the gaseous
emissions must meet the ambient air standards, the ash must be disposed off
properly
The third party monitoring being proposed under the HCWM Plan could address
these issues on a periodic basis. The ash from the incinerators should be disposed of
in the landfill site. In the smaller towns, rural areas and remote places where
incinerators are used the ash could be disposed of to the burial pit.
o Mechanism to have separated General Waste Collected by the Municipalities
78
o If BMW is transported to a CWTF, it must be done in designated closed vehicles
carrying Bio-hazardous symbol & duly approved by NEPA/MoPH.
o The HCU building meets the construction guidelines of the MoPH
o The Sanitation & drinking water quality is of acceptable.
VIII. BUDGET
Phased Manufacturing Program
It is suggested that keeping in view the local domestic manufacturing capabilities, and the
volumes of the different equipment & products required under the HCWMP, adaptability to
different levels of technology etc. A time-bound Phased Manufacturing Program (PMP) is
implemented in a manner that there is a definite trend towards indigenization in a phased manner.
A proposed PMP for the major equipment & consumables to be procured under the HCWMP is
as follows (Table 21):
Table 21: Phase Manufacturing Program for the major Equipment & consumables
S. No. Item Indigenization/Local
Procurement Time
Frame
1. Safety Gears, Colored Bins & Bags, Trolleys, Sharps
Safety Boxes
5-6 Months
2. Construction of Deep Burial Pits & Secondary
Storage/VATS at HCUs
6-8 months
3. CWTF Construction & operation 9-12 month
4. Procurement of Incineration *, Autoclave * and
Shredders *
18-24 months
*The important controls, sensors, thermostats & instrumentation may continue to be imported
while the fabrication and final assembling may be indigenized within 2 years’ time frame.
Procurement Policy
A detailed Procurement Policy needs to be developed by the MoPH in consultations with the
other stakeholders and in conformity with the proposed HCWM Policy framework. The CWTF
model is proposed to be implemented on a PPP mode where Private Sector investment is
envisaged. However, the initial projects are expected to be Pilot Projects where funding has to
come from MoPH. The large & more expensive equipment could be procured at the
Regional/Provincial level.
A viable Procurement Policy decentralized purchase of PPE, Bins, Bags, Trolleys etc. at the HCU
level with clearly identified set of supplier, is required to be developed. The managing NGOs
would have to be properly apprised about this policy. A listing of specifications of the major
equipment including a list of the potential suppliers, both domestic & foreign, needs to be
developed and shared with all stakeholders.
The Procurement Plan should be dovetailed with the implementation of the HCWM Plan to
ensure that the equipment is in place when the proposed plan is being implemented at the ground
level.
The procedures for procurement also need to be developed. A separate document on the
Procurement Policies and Procedures to be used by all the stakeholders, need to be developed by
the time the HCWM plan is implemented.
Financing
There is a need to work out and implement innovative models for financing the HCWM plan and
operations in Afghanistan given the budgetary constraints of the Government. A PPP model with
active participation of the Private Sector in HCWM would go a long way in implementing an
effective HCWM Policy Framework and implementing projects at the ground level.
The concept of user fees needs to be incorporated in the PPP model to ensure sustainable
operations for the Private to invest in these projects. The Capex and the Opex for the project
79
could be recouped through a user-fees mechanism in which the HCU can pay the operator on a
per bed basis .The revenue generated from the User-Fees over a period of time (15 years) could
offset the initial investment as well as the operating costs of the Private Operators while ensuring
an adequate return. This approach may become even more relevant in the case of CWTFs where
substantial investments and costs would be required as well as a high level of technical
competence and expertise on part of the private operator.
The user fees are expected to offset the financial requirements to sustain the HCWM plan in the
subsequent years.
A mode to develop a “User Fees” based on the “Polluter Pays” principle needs to be developed
for the HCUs using the facilities of a CWTF for the treatment of HCW treatment & disposal. The
daily user fees could be based on a fixed amount per bed basis and is likely to be in the range of
7-10 Afghanis.
The user fees would have to be paid by the HCU to the CWTF operator. A successful
demonstration of this model should be provided to the important stakeholders who will undertake
the exposure visits to the neighboring country.
COSTING
The costing of training and Capacity Building at various levels has been worked out as under:
1. Waste Management Committee
2. Doctors
3. Nurses and Para-Medical Staff.
4. Sanitation Workers
5. Administrators
The training cost likely to be occurred has been worked out at Table 22. These costs have been
worked out on the basis of average number of participants, duration of training, training module
etc.
For training and capacity building including IEC material requirement at various levels and
orientation program and TOT (Training of Trainers) have been worked out for Five years. Figure
10 is illustration of fund requirements for training and capacity buildings at various levels.
The wages and salaries of the technical & maintenance staff as well as the costs for 3rd
party
M&E of HCWM plan implementation have not been covered in the financial estimates.
Figure 5: Year wise Investment Required
0
500000
1000000
1500000
2000000
2500000
3000000
1st Year 2nd year 3rd Year 4th Year 5th Year
US$
80
IEC Material
IEC material (POSTERS, DISPLAYS, STICKERS, BANNERS) play a major role in
disseminating the information and creating awareness among the various stakeholders and the
public at large.
The IEC material needs to be developed on the following subjects:
- Usage of PPE(Directed at the Nursing Staff, para-medical staff)
- Waste Segregation at source (For Nursing Staff and Para Medical staff)
- Safe Disposal of Sharps(For Nursing Staff and Para Medical Staff)
- Color-coding of different types of Wastes (For Doctors, Nurses, Para-Medical Staff,
Sanitation workers and the Public )
- IEC Material for public focusing on usage of Black Bins for General Waste
The IEC Material should be in Dari and Pashto and must be prominently DISPLAYED at
all relevant strategic points in the HCF.
The cost estimates of the designing & printing of the IEC material have been worked out &
presented in Table 22.
INVESTMENT REQUIREMENT FOR TECHNOLOGY UPGRADATION AND NEW
PROCUREMENTS
Based on the estimate of Healthcare waste generation in the country, it broad requirement of
technology and equipment for overall effective management of Health Care Waste in
Afghanistan has been worked out.
The proposed 6 nos. each of the incinerators, autoclave, plastic shredders as part of the pilot
projects for common waste treatment facilities in the six major provinces i.e. Kabul, Kandhar,
Balkh, Jalalabad, Herat and Ghazni would be funded under the SEHAT project in Phase I.
The subsequent CWTFs are proposed to be implemented by the private agencies under the PPP
mode based on the experience gained from the first six facilities. Therefore no separate funding
for the facilities proposed under the PPP arrangement have been provided for.
The following table (Table 22) illustrates the investment requirements during the next five years.
T
TOTAL FINANCIAL REQUIREMENTS FOR IMPLEMENTING HCWM
Total Financial Requirements for implementing the HCWM plan in Afghanistan over the five
year period could be summarized as under (Table 23).
Year Training, Capacity Building and
IEC (USD)
Investment Budget
(USD)
1st Year 990000 1631500
2nd Year 885000 2603000 3rd Year 615000 2523000
4th Year 635000 1814000
5th Year 595000 1325000
G. Total 3,720,000 9,896,500
Name Nos Unit Price
(USD$)
Incinerators (25kg/hr) 6 50000
Autoclaves/Microwave (15 kg/hr) 6 20000
Plastic Shredding (15kg/hr) 6 10000
Deep Burial Pits 25 500
Sanitary Landfilling *
LS
Puncture Proof Bag 200000 2
Bins 12000 10
Bags 200000 1
Trolleys 2000 50
Vehicles 20 15000
Building & Construction 6 1500
81
Table 22: Estimate of Financial Requirement for Training, Capacity Building and IEC (US Dollar)
S.N
1st Year 2nd Year 3rd Year 4th Year 5th Year
No. of
Program
Cost Total No. of
Program
Cost Total No. of
Program
Cost Total No. of
Program
Cost Total No. of
Program
Cost
Total
1 Orientation
Program and
training the
trainers (incl.
NGO)
4 20000 80000 2 20000 40000 2 20000 40000 0
2 Provincial
Level Training
70 5000 350000 35 5000 175000 35 5000 175000 35 5000 175000 35 5000 175000
3 District Level
Training
100 2000 200000 100 2000 200000 100 2000 200000 100 2000 200000 100 2000 200000
4 MoPH
Capacity
Building
2 20000 40000 1 20000 20000 1 20000 20000 0 0
5 PHCs and
HSCs HSCs
0 200 1000 200000 200 1000 200000 200 1000 200000 200 1000 200000
6 Training
Manual
Lump sum 20000 20000 0 0 0
7 Familiarization
Site Visits
1 200000 200000 1 200000 200000 0 0 0
8 IEC 50000 2 100000 25000 2 50000 10000 2 20000 10000 2 20000 10000 2 20000
Grand Total 990000
885000
615000
635000
595000
Note: Four Orientations cum Train-the-trainer programs are planned in the initial phase. Similarly the Provincial level training programs (app. 2 per Provinces in the 1st year) have been
planned coupled with Decentralized District level Training programs for the Smaller HCFs. Two programs to orient the various departments of the MoPH on the HCWM Concepts and
Plan Implementation are also proposed. Familiarization visits for the major stakeholders for the existing facilities in the neighboring countries in the 1st, and 2
nd year are also planned.
Table 23: Estimate of Financial Requirement for Technology Up-gradation and new Procurement (US Dollar)
S.
1st Year 2nd Year 3rd Year 4th Year 5th Year
No.s Unit No.s Unit Amoun No.s Unit Amoun No.s Unit Amoun No.s Unit Amoun
82
N Price Amoun
t
Price t Price t Price t Price t
1
Incinerators
(25kg/hr) 6 50000 300000 12 50000 600000 12 50000 600000 6 50000 300000 0
2
Autoclaves/Microw
ave (15 kg/hr) 6 20000 120000 12 20000 240000 12 20000 240000 6 20000 120000 0
3
Plastic Shredding
(15kg/hr) 6 10000 60000 19 10000 190000 12 10000 120000 6 10000 60000 0
4 Deep Burial Pits 25 500 12500 50 500 25000 50 500 25000 50 500 25000 50 500 25000
5
Sanitary Landfilling
* LS 10000 LS 10000 10000 0 0 0
6 Puncture Proof Bag
20000
0 2 400000
40000
0 2 800000
40000
0 2 800000
40000
0 2 800000
40000
0 2 800000
7 Bins 12000 10 120000 12000 10 120000 12000 10 120000 20000 10 200000 20000 10 200000
8 Bags
20000
0 1 200000
20000
0 1 200000
20000
0 1 200000
20000
0 1 200000
20000
0 1 200000
9 Trolleys 2000 50 100000 2000 50 100000 2000 50 100000 2000 50 100000 2000 50 100000
10 Vehicles 20 15000 300000 20 15000 300000 20 15000 300000 0 0
11
Building &
Construction 6 1500 9000 12 1500 18000 12 1500 18000 6 1500 9000 0
Total 163150
0
260300
0
252300
0
181400
0
132500
0
Note: 6 Pilot Projects for CWTF (Comprising of Incinerator, Autoclave/Microwave and Plastic Shredders) are proposed to be implemented in the 1st year. The estimate, for the burial pits
is based n the HCWM requirements of those HCFs which would not have access to the CWTFs. The estimate for Bins, Bass, Trolleys and Vehicles (for transport of HCW from HCFs to
the CWTFs) is based on the broad requirements per facility.
0
Disclosure
This preliminary Health Care Waste Management Plan was developed by the MoPH on the basis of review of
existing practices in the sector. Prior to approval of the SEHAT project by the World Bank, the preliminary
HCWMP was disclosed on November 28, 2012 by MoPH in Afghanistan on the MoPH website, Libraries,
HQ and provincial offices, MoPH implementing partners offices and by the WB Infoshop.
This comprehensive HCWMP is developed based on the recommendation of preliminary HCWMP which
would be cleared by NEPA and The World Bank before the complete disclosure of the same is made on the
relevant websites and public discussions with all stakeholders are completed.
The HCWMP after the Public Disclosure and approval of the stakeholders would be made operational.
1
ANNEXURE I: MAJOR SCOPE OF WORK
2
Annexure II
THE MAJOR SCOPE OF WORK FOR THE COSULTANT
Task 1: Assessment of Existing Policies and Waste Management Practices
i) Assess the policy legal and administrative framework as well as the regulatory
framework on health-care waste management and treatment in the country. This
includes air emission standards, which are currently required by law for the next ten
years.
ii) Identify permit requirements including environmental building and the other
procedures that healthcare waste management facilities would need to address and the
time demands to obtain these permits. In this respect, identify the environmental
impact requirements and public participation requirements.
iii) Assess the health-care waste generation at randomly selected facilities. The details
should include the minimum weight of total generated wastes at each health-care
facility per week. Composition of the waste should be determined through segregation
at the waste end point and the results should be extrapolated to cover the entire
country.
iv) Review and analyze existing health-care waste storage, collection and disposal system
at the randomly selected facilities with due regard for level of separation, frequency of
collection and environmental –through soil, surface and ground water and air
resources- and health impacts for existing treatment.
v) Assess the level of scavenging, if any, or recycling taking place inside health-care
facilities, along transportation routes, and at final sites. Determine social issues in
relation to scavenging taking place.
Task 2: Determination of Technology and Siting
a) Determination of Technology
For the types and quantities of health-care waste generated in the study, assess the
different types of technology and facility sizes available for treatment and destruction. The
assessment shall compare alternatives on the basis of capital cost, operation cost, ease of
operation, local availability of spare parts, local availability of operation skills,
demonstrated reliability, durability and environmental impact. The technologies to be
considered include; burial pits for safe land filling, incineration, sterilization (autoclave
and microwave) and chemical disinfections. On the basis of this assessment, recommend a
3
process flow for economic and environmentally sound treatment and final disposal of
health-care waste.
b) Determination of Disposal Sites Analysis of the Site
Analyze the above information to determine whether there is sufficient appropriate
material on site for daily and final cover, and whether the soil, hydrological and geo-
hydrological conditions would ensure adequate protection of any ground and surface water
used for drinking and/or irrigation. If the sites prove to be unsuitable, inform the client
stating the reasons.
c) Financing
Assess alternative approaches for financing the treatment and disposal activities. Assess
public-private partnerships and cost recovery at the regional, municipal level based on the
polluter pays principal, where each health facility pays according to the volume of waste
generated. Assess private sector participation as service provider.
d) Public Consultation
Public consultation with beneficiary groups, institutions, NGOs and Community Based
Organizations and other interested parties be held as part
Task 3: Training and Public Awareness
i. At the randomly selected facilities surveyed as part of Task 1, assess awareness of
health workers of safety risks, correct procedures for collecting, handling and disposing
of health-care wastes.
ii. Review existing training and public awareness program on health-care waste
management at hospitals and other health-care establishments and prepare training
needs assessment.
iii. Working in conjunction with relevant government institutions and municipal councils,
prepare a costed training program targeting the general public, health-care workers,
municipal workers, dump site managers, incinerator operators (if that is the choice of
technology), nurses, scavengers/pickers, families and street children.
iv. The design of the material required for the awareness/capacity building programs
should be discussed with the relevant authorities and the general public to ensure that
their concerns that are deemed appropriate are incorporated in the design of the
program, sitting layouts, mitigation measures and community communication
programs.
v. It is understood that some of these training materials should be developed later on
during the implementation of the project.
4
vi. Assess the institutional capacity of HCWM in the MOPH and make recommendations
so that MOPH take care of the implementation of the HCWM appropriately.
Task 4: Public Consultation and draft policy, Plan and Training Program
The training and awareness building program and the waste management program shall be
appropriately costed and the plan of action shall be presented in a national workshop.
Following the stakeholder consultations, the consultant(s) shall revise the draft reports in
accordance with the comments of the Government, WHO, The World Bank, and other
relevant institutions in the donor community and other interested parties and submit the final
report incorporating all changes and modifications as required. The Consultant is expected to
provide the report with pictures and maps where necessary to the government and the Bank.
5
ANNEXURE II: COPY OF THE QUESTIONNAIRES USED
0
Annexure III
QUESTIONNAIRE FOR HEALTH FACILITIES
1. Name & Address of the : Hospital/Healthcare center
2. Type of Healthcare Centre :
3. Name & Designation of : Responding Person
4. Population of City/Town :
5. No. of Beds in Hospital – what is occupancy rate? How many OPD patients on an average?
6. What kind of care is primarily provided – e.g. immunization, deliveries, HIV, TB, Minor Surgeries, OPD etc.
7. Are you aware of the HCWM concept and the Policy? Is your facility in compliance? Have you received all the necessary clearances for implementing the policy?
8. What steps have been undertaken to improve the HCW Management in your Healthcare facility l? How has HCW Management progressed over time with the implementation of the various Government‘s initiative in the Health Sector?
1
9. What is the quantity and mode of disposal of different types of wastes generated at your hospital?
S No.
Nature of Waste Quantity Generated
Per Day
Method of
Treatment/
Disposal
1
Outdated Drugs, Chemicals and
disinfectants used in Labs & for
Decontamination of Needles
etc.
2
Syringes, Conules,
Catheters, (Infectious Plastics)
3
Pathological and anatomical
Waste, Infectious Waste,
Infected Blood, Cytotoxic
waste, etc.
4
Glass Waste (both broken
and non-broken)
5
Needles, Blades and Scalpels
10. Do you use reusable syringes? Do you have sterilization equipment in place?
11. What is the mode of collection and transportation of different types of waste generated at the Healthcare Unit?
2
12. Is there any color-coding used being for collection of different types of wastes? Please elaborate.
Type of Waste Color of Container
and markings
Type of container
Highly Infectious
Waste
Red Strong Leak-proof plastic bag or
container capable of being
autoclaved
Other infection waste,
pathological and
anatomical waste
Yellow Leak-proof plastic bag or
container
Sharps Yellow, marked
“SHARPS”
Puncture-proof container
Chemical and
Pharmaceutical waste
Brown Plastic bag or container
Radioactive Waste - Lead box, labeled with the
radioactive symbol
General Healthcare
waste
Black Plastic bag
13. Are these consumables expensive?
14. Are they provided under the project or do they acquire them using user fees?
15. How will this be sustained after project life?
16. Have you come up with any innovative ideas for collection?
17. Is there any wastage (e.g. small volumes in large bags etc.)?
18. Are you using chlorinated plastic bags? Or are they non-chlorinated and if so are the costs higher?
19. What is the durability of the bins provided under the project? Please elaborate.
20. Do you have in-house facilities for treatment of infectious wastes & other wastes? If yes, please give details.
3
21. In case you are using incinerator at your premises, please provide details on the equipment used & its technical features.
22. How is the residue from the incinerators disposed off?
23. Do you experience any difficulty in the operation and maintenance of the equipment installed at the hospital for HCW treatment (e.g. Autoclaves, incinerator, and Microwave equipment)? Please give complete details
24. What is the durability of the equipment provided under the project?
25. What is the better technology between hydroclaves, microwaves and autoclaves?
26. Do you have deep burial pits for final disposal?
27. Is there a recycling system in place for the plastics and glass?
28. How durable are the needle cutters/destroyers?
29. Are they being effectively used in all wards?
30. If No, are your using external facilities such as Common Waste Treatment Facilities (CWTFs) for treatment & disposal of waste?
31. How is the HCW transported to the CWTF?
32. What are charges per ton of HCW paid to CWTF?
33. What is the average quantity of HCW sent to CWTF for treatment? Please Elucidate.
34. What is the level of awareness and training provided to the different levels of staff for better HCW management in the hospital?
35. How often has training been provided? Is there ongoing refresher training?
4
Type
Level
General
Ongoing
Awareness
Refresher
Training
About
HCWM
Frequency
Doctors
Nurses
Technician
Sanitary &
Lower Level
Staff
36. Who monitors the effective implementation at each facility?
37. How often does the HCWM Team meet?
38. What do they discuss and evaluate?
39. Who is in charge of daily operations?
40. Did you experience any difficulty in obtaining clearances/assistance from the regulatory bodies? Please elaborate.
41. Did you receive adequate assistance from the Ministry of Public Health/Project Management Unit?
42. Have any guidelines/plans been provided to you by the Government?
43. What has been the attitude of the community /NGOs/people at large?
44. Have they contributed towards achieving better HCW Management at the Hospital?
5
45. Are you aware of the environmental and health implications of HCWM?
46. Which major difficulties/constraints have you faced in implementing better HCW Management Systems at the hospital?
47. Which are the critical issues (Both External & Internal) ?
48. Which determine the success of a HCW Management System? Please elaborate.
49. Which are the 3-4 major actions you have taken to improve the HCW management at the Facility?
50. Are any External Agencies such as Independent M&E organizations and/or NGOs who are working with you? Please provide details
108
Islamic Republic Of Afghanistan
Ministry Of Public health
Preventive Medicine General Directorate
Environmental Health Directorate
HCW Disposal Project
HCW Disposal Standards
109
Name of Province-------------- Name of Health Facility----------------- No Of Beds------- Catchment area population-----------------
-----------
Assess # 1-2-3-4-5, Date of Assess ---------------- Assess Team------------------------- No of Delivery/ Operation / Month------------
-----------
Comments 1 0 Standards/ Sub Standards Standard
/ Sub
Standard
#
Total: I: - Hospital has a HCW disposal committee or HCW disposal team incorporated as part of infection
prevention ToR.
Committee consists of key members of hospital departments ( Hospital director
or deputy, in charge and head nurse, Gyn/Obs, surgery, internal medicine chiefs,
OT nurse, and hospital admin)
1.1
One person selected as focal point for HCW among committee members 1.2
Written and signed ToR exist for committee which explains the responsibilities 1.3
Committee has regular meetings( weekly, bi weekly, or monthly as per need)
please refer to minutes of the meeting 1.4
Committee has work plan mentioning gaps, interventions, responsible person,
and end date of action 1.5
Total: II:- Committee members have received HCW disposal training
HCW Disposal training conducted for members of the committee 2.1
The training covers waste segregation, collection, storage, transportation,
treatment, accident and spillage. The training consists of theory and practical
stations
2.2
There is an action plan development at the end of training (cascade of training
and change of knowledge into practices) 2.3
110
Comments 1 0 Standards/ Sub Standards Standard
/ Sub
Standard
#
Trainings adapt and conduct for different level according to level of knowledge
and understanding 2.4
HCW disposal included in list of hospital conferences 2.5
Total: III:- There is designated place and equipment for HCW disposal in health facility
Personal Protection Equipment (PPE) exists adequately for OT, dressing
room, delivery room, Lab, and other wards (caps , masks, safety eye glasses,
aprons and boots)
3.1
Plastic bags with the same color coding as the bins exist in wards, OT, dressing
room, delivery room, corridor and compound 3.2
Safety box exists in delivery room, OT, nursing and midwives room ( Not
accessible to the patients and their companions) 3.3
There is special place for the temporary storage of HCW in the health facility 3.4
The storage area is surrounded by wall or wire with lockable door,is out of the
reach of the children, animals and irresponsible persons with clear written and
pictorial alert signs
3.5
Total: IV:- HCW segregation exists in health facility
Red bin with red plastic for anatomical and pathological bio HCW
(dressing, placenta, part of body, lab waste)
Yellow bin and plastic for other infectious HCW (empty bottle of serum,
syrup, vial, used syringe, etc.
Black bin with black plastic for general waste ( food, dust, recyclables )
4.1
Doctors, nurses and people who deal with HCW, segregate the HCW at the
production site into hazardous and non-infectious 4.2
Sharps (Needle, surgical blade, suture needle, broken ampules put into safety
box. 4.3
Seal the plastic bag before transportation 4.4
Plastics will transport to incinerator, land fill, burial and laundry room 4.5
Total: V:- HCW collection is available in the health facility
Bins will evacuate when 3/4th
filled or at the end of the day, after each delivery
or operation 5.6
111
Comments 1 0 Standards/ Sub Standards Standard
/ Sub
Standard
#
The sealed waste plastic labeled with date of production, place and the contents 5.2
Change the plastic of bin after r emoval of waste 5.3
Wash the bin after exchange of old plastic into new plastic 5.4
The is pictorial guide close to each bin which help the patient and accompanies
in segregation of HCW 5.5
Total: IV:- HCW storage system is available in health facility
HCW is transporting before 24 hours from storage area( HCW should store
between 3-8⁰ )be 6.1
The land fill is cleaning regularly 6.2
The container which has chemical waste should store in separate room 6.3
The health facility is not receiving drug with less than six months shelf life 6.4
HCW management is open for 24 hours 6.5
Total: VII:- the is proper transportation system for HCW
The edge of HCW trolley and wheel barrow are blunt and will not produce
injury during cleaning 7.1
During HCW transportation the staff has personal protection equipment 7.2
Trolley, wheel barrow and the car is used just for HCW transportation 7.3
HCW transportation will conduct from land fill 7.4
HCW transportation should conducted by authorized team or company which
has legal license 7.5
Total: VIII:- There is proper HCW treatment system in health facility
Cannula, broken ampules, surgical blades and sharps put in safety box 8.1
Used syringe, empty bottle of serum, and vials ‘bottle put in yellow bag and bin
after decontamination with 0.5% chlorine for recycling or go for shredder 8.2
Placenta, surgical pads, part of body, expire blood and lab waste is going along
with other hazardous bio-HCW in red labeled plastic though wheel barrow or
trolley into incinerator or land fill
8.3
There is segregation system before treatment of waste 8.4
In land fill segregated waste are not mixing again 8.5
112
Comments 1 0 Standards/ Sub Standards Standard
/ Sub
Standard
#
Total: IX-A:- The ( Regional, Provincial or Tertiary) hospital has standards incinerator or IX -B
The capacity of incinerator is according number of beds or utilization of beds(
0.3-0.5 Kg waste/ bed/day) and has scrubber 9.1
Incinerator has two chambers 9.2
Incinerator has thermometer in outside to show the temperature of inner side 9.3
Incinerator is working both in fuel and electricity 9.4
Incinerator has long chimney pipe ( around 40 feet) 9.5
Total: IX- B:- The health facility has HCW burial system ( Remote clinics or low utilized
There is three well in health facility 9.1
First well for placenta, part of body, contaminated gauze pad or compress( Bio
HCW) 9.2
Second well for sharps and safety box 9.3
Third well for food and general waste 9.4
The wells and land fill located in premises of health facility which is less risky
for environment and water source 9.5
Total: X-A:- The ( Regional, Provincial or Tertiary) hospitals’ incinerator working according to guideline or
Incinerator surrounded with wall, wire and is inaccessible for children and
animal. Top of incinerator covered to protect from sun, rain snow
10.1
Incinerator is installed in premises of hospital away from common road and food
preparation area ( This area should select by team from representative of
hospital, environmental health, municipal sanitation department and NEPA)
10.2
The is storage place close to incinerator for red plastic bin material 10.3
The temperature of first chamber is over 800 celsius and second chamber is over
1000⁰ 10.4
The ash of incinerator is properly placed well or put in safe plastic bag separate
from municipal general waste 10.5
Total: X-B:-The HCW is treating in better way in remote, OPD clinics
People dealing with HCW has personal protection equipment 10.1
There is no access in wells except responsible people 10.2
The wells designed with written and pictorial alert sign 10.3
113
Comments 1 0 Standards/ Sub Standards Standard
/ Sub
Standard
#
There is no sharps and waste around HCW 10.4
In case if the well fills, cover the surface with soil and dig a new well 10.5
Total: XI-A: The ( Regional, Provincial or Tertiary)hospital has complementary part of incinerator or
The health facility has microwave and autoclave 11.1
Recycling material ( Syringe, serum bottle and vial) first sterilize in autoclave 11.2
The recycling material goes to shredder after autoclave 11.3
The shredded material go either back to company or burial area 11.4
In case the shredded material goes to burial, it should put into yellow plastic 11.5
Total: XI-B: The health facility treatment the HCW by using the other health facility equipment (Common
Treatment Facility)
The hazardous HCW (Bio Medical) put in red plastic and send to closed health
facility’s incinerator by per plastic or per bed / month charge
11.1
The recyclable material ( syringe, empty bottle of serum ) after decontamination
in 0.5% chlorine put in yellow plastic and send to autoclave and shredder by
payment charge
11.2
The general waste put in black plastic and transport with help of municipal
sanitation department to general waste land fill area
11.3
The vehicle for transportation of HCW is washable, wash the car after each
transportation and cover the surface of HCW during transportation,
11.4
The vehicle for HCW transportation has special permission letter or license and
clearly texted HCW transportation vehicle…..
11.5
Total: XII: There is awareness program regarding HCW in health facility
HCW disposal is one topic of health education program 12.1
IEC material is available regarding HCW awareness and precaution for health
provider and community
12.2
IEC material responding the need of community( Age, language and gender) 12.3
Culture sensitivity respected in IEC material and key health massages 12.4
IEC material posted in area which community has more access 12.5
Please observe the XIII standards if there is accident or hospital spillage or increase infectious complication
114
Total: XIII: in case of accidental injury or spillage the hospital takes precaution
Evacuate and clean the area 13.1
Decreases the exposure of staff and increases immunization program 13.2
Place back the taken equipment 13.3
Provide orientation for staff regarding identification and treatment of hospital
contamination
13.4
The responsible person should investigate the cause of accidental injury and
spillage
13.5
Summary table of HCW disposal checklist
13 Number of standards
75 Total of sub standards
Number of sub standards achieved one
Percentage of achievement ( Total of substandard score multiply to 100 divided to 75)
In order to prioritize in planning list the standards from low to high score
115
ANNEXURE III: LIST OF CONTACTS
116
ANNEXURE IV: LIST OF CONTACT
S.
N
Organization Address Contact Person Designation Phone 1 Phone 2 Email1 email 2 website
1 Kabul
Municipality
Mr. Nessar Ahmad
HabibiGhori
General Director
for Sanitation of
Kabul City
93 0 799
025299
2 Islamic
Republic of
Afghanistan,
National
Environmental
Protection
Agency
Zabihullah Habib
Afrooz
Director of Policy
& Legislation
[email protected] [email protected]
.af
3 Islamic
Republic of
Afghanistan,
Ministry of
Public Health
Mr. Mashal,
Mohammad Taufiq
MD
General Director of
Preventive
Medicine
93 0 708 284
144
202 301 359 [email protected] [email protected]
c.jp
4 Islamic
Republic of
Afghanistan,
Ministry of
Public Health
Mr.Amanullah
Hussaini
Environmental
Health Director
93 0 700 294
312
93 752
003542
om
5 The World Bank Mr. Mohammad
Arif Rasuli
Senior
Environmental
Specialist (South
East Asia)
93 700 171
338
87 376 346
7626
[email protected] www.worldba
nk.org/af
6 The World
Bank,
House 19,
Street 15,
Wazir Akbar
Khan, Kabul
Afghanistan
Dr. G. Sayed Senior Health
Specialist
Afghanistan
Country Office,
South Asia region
93 701 133342
(office)
93 700
042585
[email protected] www.worldba
nk.org/af
117
7 The World
Bank,
House 19,
Street 15,
Wazir Akbar
Khan, Kabul
Afghanistan
Mr. Mohammad
TawabHashemi
Extended Term
Consultants (South
Asia Region)
930 799 791
128
rg
www.worldba
nk.org/af
8 EPOS Parwiz Sardar
Mohammad
Technical Advisor
to G.D of
Preventive
Medicine (MoPH)
93 079
9311532
om
9 Islamic
Republic of
Afghanistan,
Ministry of
Public Health,
GCMU
Dr. Mohammad
Hassan
Grant Consultant 93 773 342
830
93 0 700
259 636
.af
edrishassan05@yahoo.
com
10 Islamic
Republic of
Afghanistan,
Ministry of
Public Health,
GCMU
Dr. Mohammad
Saeed MD, EMBA
PGC Grant
Consultant
93 0
700083428
[email protected] dr.muhammadsaeed@
gmail.com
12 Islamic
Republic of
Afghanistan,
Ministry of
Public Health
Pbox : 421 ,
Kabul AFG,
Macrorayan,
Kabul -
Afghanistan
Dr. Abdul Malik
"Malik"
Head of
Department
Radiation
Protection and
Nuclear Medicine
93 0
700205675
m
Abdul.Malik.Dr@gma
il.com
13 Islamic
Republic of
Afghanistan,
Ministry of
Public Health,
GCMU
Shala
Salim/MD/DPH
Communication
Officer
93 0 79
0075068
af
14 Islamic
Republic of
Afghnistan,
Ministry of
Public Health
Eng. Gh.
Mohammad Salem
Administrative
Manager
93 0 799 772
766
118
15 Islamic
Republic of
Afghanistan,
Ministry of
Public Health,
GCMU
Dr. Zahidullah
Rasooli MD
Project Manager to
Support the Public
Health Sector
93 0 787 298
233
.af
zahidullah.rasooli@g
mail.com
skype.zahidull
ahrasooli
16 Directorate of
Environmental
Health
Indira
Gandhi
Hospital,
Kabuli
Dr. Naseer ICRC
Head Quarters
(ARCS)
Bio Medical Waste
Project Manager
799108997 [email protected]
17 Construction
Department,
Ministry of
Public Health
Eng. Kamal 78300580
18 Indira Gandhi
Hospital, Kabul
Dr. Yusuf Zai Director
19 Grant Contracts
& Management
Unit, MoPH,
Afghanistan
Ghulam. Sarwar
Hemati,
Managing Director,
EMBA
93 0 799 318
328
93 0 705
470 685
.af
om
20 EPOS MoPH, G.
Massoud
Square,
Wazir Akbar
Khan Mena,
Kabul,
Afghanistan
Mr. Jordi Benages, Team Leader 93 0 78451338 [email protected]
21 Parwan Public
Health
Directorate
Alhaj Dr. Khaja M.
QasimSaidi
700271479 [email protected]
m
22 Khatiz Public
Health
Association
(KPHA)
Kabul,
Afghanistan
Dr. Said Habib
Arwal
President 9.30701E+11 9379911381
6
[email protected] skype: dr.arwal1
23 GCMU, Kabul,
Afghanistan
SahebullahAlam,
MD
Grant Consultant 9.30706E+11 9.30706E+1
1
f
smohammadalam@ya
hoo.com
119
24 EPOS MoPH, G.
Massoud
Square,
Wazir Akbar
Khan Mena,
Kabul,
Afghanistan
Dr. Hidayatullah Technical Advisor
to G.D of Curative
Medicine (MoPH)
93 0 799 127
717
m
25 Directorate of
Environmental
Health
Department
Balkh OPH
Dr. Ab. Khalil
Merhabi
0777511313-
0700511313
om
26 GCMU, Kabul,
Afghanistan
Masoud Ahmad (
Yawar), MD
Grant Consultant 9.30701E+11 drmasoudahmad@yahoo.
com
massoud.gcmu@moph
.gov.af
27 Ministry of
Public Health,
Islamic
Republic of
Afghanistan
Dr. Fazal
Muhammad "
Ibrahimi"
Advisor to Minister
, General Director
of Khair Khana102
Beds Hospital
202401352 706088572
28 Food and
Agriculture
Organization of
the United
Nations
Ministry of
Agriculture,
Irrigation and
Livestock,
General
Department
of Policy and
Planning,
Jamal Mina,
Karte Saki,
Kabul,
Afghanistan
Hafizullah Saadat National
Economist/Statistici
an
rg
Hafiz_Saadat@yahoo.
com
www.fao.org
29 EPOS, MOPH Dr. Hidayutallah TA to GD of
Curative Medicine
+93079912771
7
m
30 RBH Hospital Dr. NajiaAlami, Obst/Gyano 0779361698
31 Malalai Hospital Dr. Nasrin
Oynakihil
Trainer Spl. Ob-
Gyn.
0799326087 [email protected]
om
120
ANNEXURE IV: GUIDELINES FOR SETTING UP WASTE MANAGEMENT
COMMITTEE
121
Annexure V
Setting up of Waste Management Committee at the Facility Level
Under the Infection Control Policy, for the purpose of the implementation of HCW management Plan at
Facility Level, each and every health care facilities irrespective of their size setting up of the Healthcare
Waste Management Committee needs to be made mandatory and a written commitment (for instance
through Affidavit) needs to be furnished by the top Management/Authority of the Health Care facilities to
the Environmental Health Directorate (EHD).
The management needs to reveal names of the members of the committee and their respective roles. It
would be the responsibility of the committee to monitor and supervise the best practices of Health care
Waste Management at HCFs Level.
The Healthcare Waste Management Committee should include:
1 Heads of the Hospital
2 Waste Management Officer
3 Heads of the Hospital Departments
4 Nursing Superintendent
5 Doctor/Nurse from Infection Control Committee
6 Sanitary Supervisor
7 Store-in Charge and
Continuing
Education
Implementation of
the system
Regular Monitoring
Epidemiology Nurse
(Infection Control Nurse)
Medical Director &
Administration Head
Members from other
department
Waste Management
Committee
Policies & Regulations
Hospital’s Nodal Officer
Nursing Superintendent
Sanitary supervisor store in Charge
122
8 Other Housekeeping Staff
The HCWM Committee will also inform Environmental Health Directorate (EHD) about the selection of
treatment technology. For selection of Treatment Technology the assessment and projection of wastes to be
produced at HCFs level needs to be done.
An effective waste management plan includes the following:
Strategy to implement 3R Application (Reduction at Source, Re-Use &Recycling)
Segregation
Composting
Basic Steps in development of a Waste Minimization Program include:
a) Planning & Organization : Getting top management to be committed to waste minimization and
setting up of goals and task force by involving crucial personnel from key departments
b) Assessment: Assessment of wastes flow, waste generation rates by using an audit tool which helps
in prioritizing the waste stream based on quantity, toxicity, environmental impact, potential
liability and cost and other associated factors and selection of technology.
c) Feasibility Analysis: Evaluation of technical and economic viability technology etc.
d) Implementation: Getting approval of top management about the technology or new procedures
to minimize the waste, launch of educational and communication programs to reach out the entire
staff and patients or visitors who are directly involved with the waste production.
e) Period Inspection: Regular monitoring and evaluation helps in identification of new issues, staff
efficiency and education level etc., requirement of further reinforcement etc.
The Major Functions of HCWMC
o Prepare HCWM Plan, as per the guidelines and Policy laid down by the Implementing Agency
or Authority (i.e. NEPA), of its waste with the goal of protecting health and the environment.
o Implement HCWM Plan, review and update the policy, guidelines on an annual basis.
o Ensure adequate financial and human resources for implementation of the Health care waste
management Plan.
0
ANNEXURE V: GUIDELINES FOR CONSTRUCTION SHARP AND BURIAL PITS
0
Annexure VI
Guidelines for construction Sharp and burial Pits
Design Aspects of Sharps Disposal Pit
Since sharps are usually the main cause of concern, and make up only a small quantity of the total
health care waste, they may be appropriately disposed of on-site. The remaining waste may be sent
to the municipal (or common) disposal site. A system that may be used in small health care centers
is described below.
A circular or rectangular pit is dug and lined with brick, masonry or concrete rings. The pit is
covered with a heavy concrete slab that is with an internal diameter of about 200mm. Needles and
scalpel blades (without the syringe body or drip tubing) are dropped into the pit through the steel
pipe. When the pit is full it can be sealed permanently after another has been prepared. Advantages
of such pits are that these discourage recycling of sharps by scavengers due to their inaccessibility.
The height of the pipe discourages children from dropping soil or stones into the pit filling it up
prematurely.
The Specification for a Waste Burial Pit
The specification for a waste burial pit is provided below.
1 A pit or trench should be dug about 2 meters deep. It should be half-filled with waste, and
then covered with lime up to 50 cm of the surface, before filling the rest of the pit with soil.
2 Animals should not have any access to the waste burial sites. Covers of galvanized
iron/wire meshes may be used to protect the area from trespassing.
3 On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added
to cover the wastes.
4 Waste disposal into the pits should be performed under close and dedicated supervision.
5 The deep burial site should be relatively impermeable and no shallow well should be close
to the site.
6 The pits should be distant from habitation, and sited so as to ensure that no contamination
occurs of any surface water or ground water. The area should not be prone to flooding or
erosion.
7 The location of the deep burial site should be authorized by the prescribed authority
8 The institution should maintain a record of the kind of waste sent for deep burial.
1
9 A permanent Record of the size and location of all burial pits needs to be strictly
maintained and displayed at strategic place with due precautions to prevent construction
workers, builders and other from digging in those areas in the future
Figure5.3: Layout Specifications for Burial Pit
(Source “Implementation Experience in India & Tool-Kit for Managers, The
World Bank)
0
ANNEXURE VI: COMPARATIVE EVALUATION OF DIFFERENT TECHNOLOGY
1
Annexure VII
The Incinerators are being increasingly moved away from the Hospitals & HCFs, the world over
due to a host of factors including high capex&opex, space requirements, lack of technology back-
up support & technical personnel etc. apart from the environment issues. The Burial Pits for the
HCFs in remote locations as well as those which are not linked to CWTFs remain viable disposal
option.
In absence of CWTF pit technology based disposal system can be adopted. The specification for
a waste burial pit have been provided in HCWM Plan at Chapter 5 in detail.
Evaluation of Technologies
It is pertinent to evaluate the advantage and disadvantage of available technology (ies) for effective
HCWM purpose. A comparative evaluation of the technological options for HCWM has been detailed
below.
Advantage & Disadvantages of different Treatment methods
Treatment method Advantages Disadvantages
Rotary kiln
Incineration
Adequate for all infectious waste,
Most chemical waste and
pharmaceutical waste.
Significant reduction of weight and
volume of waste.
High investment and operating costs.
Concern about air emissions.
Controlled air
Incineration
Very high disinfection efficiency.
Adequate for all infectious waste and
Most pharmaceutical and chemical
waste.
Incomplete destruction of cytotoxic.
Relatively high investment and
operating costs.
Concern about air emissions.
Multiple hearth
Incineration
Good disinfection efficiency.
Significant reduction of weight and
volume of waste.
The residues may be disposed of in
landfills.
No need for highly trained operators.
Relatively low investment and
operating costs.
Significant emissions of atmospheric
pollutants.
Need for periodic removal of slag and
soot.
Inefficiency in destroying thermally
resistant chemicals, and drugs such as
cytotoxic.
Chemical
Disinfection
Highly efficient disinfection under
good operating conditions.
Requires highly qualified technicians for
operation of the process.
2
Some chemical disinfectants are
relatively inexpensive.
Reduction in waste volume.
Uses hazardous substances that require
Comprehensive safety measures and
safe disposal.
Inadequate for pharmaceutical, chemical
and some types of infectious waste.
Wet thermal
Treatment
Environmentally sound.
Drastic reduction in waste volume.
Relatively low investment and
operating costs
Shredders are subject to frequent
breakdowns and poor functioning.
Operation requires qualified technicians.
Inadequate for anatomical,
pharmaceutical, and chemical waste and
waste that is not readily steam-
permeable.
Microwave
Irradiation
Good disinfection efficiency under
appropriate operating conditions.
Drastic reduction in waste volume.
Environmentally sound.
Relatively high investment and
operating costs.
Potential operation and maintenance
problems.
0
ANNEXURE VII : GUIDELINES FOR SETTING UP OF CWTFs
1
Annexure VIII
Setting up of Common healthcare Waste Treatment Facility
A Common healthcare Waste Treatment Facility (CWTF) shall have following treatment facilities.
i) Incineration: It is a controlled process where waste is completely oxidized and harmful
microorganisms present in it are destroyed/denatured under high temperature.
ii) Autoclaving/Microwaving/Hydroclaving: Autoclaving is a low-heat thermal process where steam
is brought into direct contact with waste in a controlled manner and for sufficient duration to
disinfect the wastes. For ease and safety in operation, the system should be horizontal type and
exclusively designed for the treatment of health care waste. For optimum results, prevaccuum based
system be preferred against the gravity type system. It shall have tamper-proof control panel with
efficient display and recording devices for critical parameters such as time, temperature, pressure,
date and batch number etc.
In microwaving, microbial inactivation occurs as a result of the thermal effect of electromagnetic
radiation spectrum lying between the frequencies 300 and 300,000 MHz. Microwave heating is an
inter-molecular heating process. The heating occurs inside the waste material in the presence of
steam. Hydroclaving is similar to that of autoclaving except that the waste is subjected to indirect
heating by applying steam in the outer jacket. The waste is continuously tumbled in the chamber
during the process. Though chemical disinfection is also an option for the treatment of certain
categories of bio-medical waste but looking at the volume of waste to be disinfected at the CBWTF
and the pollution load associated with the use of disinfectants, the use of chemical disinfection for
the treatment of bio-medical waste at CBWTF is not recommended.
iii) Shredder: Shredding is a process by which waste are de-shaped or cut into smaller pieces so as to
make the wastes unrecognizable. It helps in prevention of reuse of bio -medical waste and also acts
as identifier that the waste has been disinfected and is safe to dispose of.
A shredder to be used for shredding bio-medical waste shall confirm to the following minimum
requirements.
1 The shredder for bio-medical waste shall be of robust design with minimum maintenance
requirement
2 The shredder should be properly designed and covered to avoid spillage and dust
generation. It should be designed such that it has minimum manual handling.
3 The hopper and cutting chamber of the shredder should be so designed to accommodate the
waste bag full of bio-medical waste.
2
4 The shredder blade should be highly resistant and should be able to shred waste sharps,
syringes, scalpels, glass vials, blades, plastics, catheters, broken ampoules, intravenous sets/
bottles, blood bags, gloves, bandages etc. It should be able to handle/ shred wet waste,
especially after microwave/ autoclave/hydroclave.
5 The shredder blade shall be of non-corrosive and hardened steel.
6 The shredder should be so designed and mounted so as not to generate high noise &
vibration
7 If hopper lid or door of collect ion box is opened, the shredder should stop automatically for
safety of operator.
8 In case of shock-loading (non-shred-able material in the hopper), there should be a
mechanism to automatically stop the shredder to avoid any emergency/accident.
9 In case of overload or jamming, the shredder should have mechanism of reverse motion of
shaft to avoid any emergency/accident.
10 The motor shall be connected to the shredder shaft through a gear mechanism, to ensure low
rpm and safety.
11 The unit shall be suitably designed for operator safety, mechanical as well as electrical.
12 The shredder should have low rotational speed (maximum 50 rpm). This will ensure better
gripping and cutting of the bio-medical waste.
13 The discharge height (from discharge point to ground level) shall be sufficient (minimum 3
feet) to accommodate the containers for collection of shredded material. This would avoid
spillage of shredded material.
14 The minimum capacity of the motor attached with the shredder shall be 3 kW for 50 kg/hr, 5
kW for 100 kg/hr& 7.5 kW for 200 kg/hr and shall be three phase induction motor. This will
ensure efficient cutting of the health care wastes. Other specifications have been provided at
Annexure 5.1.
iv) Sharp pit/ Encapsulation: A sharp pit or a facility for sharp encapsulate on shall be provided
for treated sharps. An option may also be worked out for recovery of metal from sharps in a
factory.
v) Vehicle/Container Washing Facility: Every time a vehicle is unloaded, the vehicle and empty
waste containers shall be washed properly and disinfected. It can be carried out in an open area
but on an impermeable surface and liquid effluent so generated shall be collected and treated in
an effluent treatment plant. The impermeable area shall be of appropriate size so as to avoid
spillage of liquid during washing.
vi) Effluent Treatment Plant: A suitable Effluent Treatment Plant shall be installed to ensure that
liquid effluent generated during the process of washing containers, vehicles, floors etc. is
disposed after treatment. The treated effluent shall comply with the stipulated regulator y
requirements.
Infrastructure Set up
The following infrastructure needs to be set up for CWTF
i) Treatment Equipment Room
ii) Main Waste Storage Room
iii) Treated Waste Storage Room
3
iv) Administrative Room
v) Generator Set
vi) Site Security
vii) Parking
viii) Sign Board
ix) Green Belt
x) Washing Room
Besides above following important provision should be made in CWTF
o A Telephone
o First Aid Box
o Proper Lighting
o Proper Fire Fighting Facilities
o Measures to control pests and insects at the site
o Safety gears for the waste handlers
o Record Keeping
0
LIST OF REFERENCES
1. Afghanistan’s Environment(2008), Executive Summary (NEPA)
2. Ministry of Public Health (MoPH) Strategic Plan(2011-15)
3. Preliminary Healthcare Waste Management Plan for SEHAT Project, MOPH (Nov 2012)
4. Mainstreaming Environmental Management in the Healthcare Sector- implementation
experience in India and a toolkit for managers vol. 1 & 2 (The World Bank, Feb 2012)
5. Healthcare Waste Mgmt Guidelines (Dari Version)
6. Afghanistan Health Profile
7. Afghanistan Provincial Health Profile-Situational Analysis of Provincial Health Services
(MoPH HMIS DEPTT.)
8. Article 'UNDP-“Health without Harm”.
9. Biomedical Waste Management RULES India (1998) and Draft BMW Rules India (2011)
10. Draft New BIO Medical Waste Management Rules
India (2011)
11. Infection Management and Environment Plan, Policy Framework, MoHFW, Govt. of India
(March 2007)
12. Rapid HealthCare Waste Mgmt tool (RAT) .WHO,UNEP/SBC,2004
13. CPCB Guidelines for establishing and operating Common Bio Medical Waste treatment
facility.
14. Manual on Safe Management of Wastes from HealthCare Facilities (WHO)
15. Guidelines for Environmental Infection Control in HealthCare Facilities (CDC, Atlanta).
16. Health Services Support Project (HSSP), July 2006-Oct 2012, USAID, Afghanistan.
17. Country Update, The World Bank Group in Afghanistan, Issue 042, March 2013.
18. Ambient Air Standards of Afghanistan, NEPA,2011.
19. Policy on MSW Management (Dari Version), Kabul Municipality.
20. World Bank Safeguard Policies (MAY 2007) and the updates
21. Technical Committee On Geotechnics of Landfill Engineering, German Geotechnical
Society(DGCT)-Toolkit for Landfill Technology, June2009
22. Extension of Consultancy services for Sanitation Improvement in Kabul City-Report of
Environment expert-Construction of New Landfill Site in
District#17.
23. Environmental Health Policy of Afghanistan (Draft)
24. Infection Prevention (IP) Plan Document, MoPH, Afghanistan
25. SEHAT Project Documents, Afghanistan
26. National Health and Nutrition Sector Strategy, Afghanistan
27. Health & Nutrition Policy
28. Afghan Private Hospital Association (APHA) Guidelines.